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1 Elizabeth Crandall, MD Ophthalmology 136 W. Cherry St Jesup, GA Phone: (912) Fax: (912) Dear, Thank you for choosing us to provide you with your eye care needs. We know you have other choices and we are extremely happy you ve given us the opportunity! Since you are a new patient, we have attached our new patient paperwork forms. We would greatly appreciate you filling out the attached forms so that we can get you seen in a timely manner. We realize it's a lot of paperwork, but we promise all this information is pertinent to ensuring we don t miss anything in your medical history! For your first visit, you can expect an average time of 1 hour for the complete visit. We strive to be very thorough with our new patient exams so that your future visits will be a breeze! During your first visit, you will also be dilated. If you haven t been dilated before, you can expect your vision to be a bit blurry for 3-4 hours after your visit. If you're uncomfortable driving afterwards, we suggest you have a wonderful friend or partner accompany you to your visit. We also advise you to bring a pair of sunglasses, or we can provide some for you. Since we are a medical clinic, we accept all medical insurance, and some vision plans such as EyeMed and VSP. Since Dr. Crandall is a medical doctor we bill medical insurance as your primary insurance, just like your primary care doctor. Your vision coverage will only cover exams that do not result in ANY medical diagnosis. Exams covered by vision insurance only provide and eye exam for glasses. With an extra charge for a contact lens exam. Please have all applicable co-pays and deductibles for your visit as they will be due at the time of service. If you are wanting contacts, there is a separate exam that can be done during your eye exam. The fee for the contact lens fitting exam is $95 and isn t covered by medical insurance, but may be at a reduced rate through your vision insurance. Finally, please bring your driver s license, insurance cards, and list of medications with you so we can enter the information we need into our system. If you are getting fitted for contacts, please bring your current contact lens boxes with you. Thank you very much for choosing us and we look forward to your visit! Regards, Elizabeth Crandall, MD
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3 Eye History Do you wear (Check box that applies) Last Eye Exam Date: None Glasses Contact Lenses Glasses and Contact Lenses Others: Please Mark Any Conditions YOU Have Presently or Have Had In The Past Dry Eyes Glaucoma Cataracts Macular Degeneration Retinal Detachment Keratoconus Others: Please Mark Any Condition YOUR FAMILY Member or Blood Relative Have Presently or Have Had In The Past Cataracts Dry Eyes Glaucoma Keratoconus Macular Degeneration Retinal Detachment Others: Betadine Allergy (Iodine) Latex Allergy
4 Distance Vision, Difficulty in: Viewing TV, reading closed caption, news scrolls on TV Seeing street signs Driving Driving at night Driving due to glare from headlights or sun Reading/viewing Blackboard Recognizing people Other: Near Vision, Difficulty in: Reading fine print, books, news paper, instructions etc. Reading fine labels (e.g. medication labels) Other: Flashing Lights: No Flashing Lights Increasing Same Sparks Lightning Bolts Arcs lasting seconds Decreasing New onset Strobe lights many minutes or longer Visual Distortion Double vision: Near Far Eyelids: Itching Burning Red Swelling Other: Ocular (Eyeballs): Dry Eyes Tearing Gritty eyes/ Mild Foreign Body Sensation Burning Itching: Mild Severe Seasonal Allergies Redness Floaters: No Floaters Increasing Decreasing Same New onset Cobwebs Black spots Headaches: Associated with visual tasks Wake up with headaches Loss of vision: Amaurosis fugax Last Minutes Complete loss of vision Loss of color vision
5 Primary Care Physician: Medical Conditions: Please mark any condition YOU have presently or have had in the past: High Blood Pressure Heart Problem Arthritis RA OA Lung Problems Stroke Thyroid Problems Uncontrolled? Diabetes Diet Non Insulin Dependent Insulin Dependent Increased Cholesterol (LDL) Cancer Lupus Others: Allergic/Immunologic & Blood/Lymphatic Seasonal Allergies Hay Fever Others: Cardiovascular Chest pain Congestive Heart Failure Irregular Rhythm Pacemaker Constitutional & Integumentary Others: Fever Weight Loss Rash Skin Disease Others: Gastrointestinal Vomiting Ulcers Diarrhea Bloody Stools Others: Medical Conditions: Conditions YOUR FAMILY/blood relative have presently or have had in the past: High Blood Pressure Heart Problem Arthritis RA OA Lung Problems Stroke Thyroid Problems Uncontrolled? Diabetes Diet Non Insulin Dependent Insulin Dependent Increased Cholesterol (LDL) Ulcers Lupus Others: Genitourinary Genital Ulcers Discharge Kidney Stones Blood in Urine Others: Head/Neck Sinus Problems Post Nasal Drip Runny Nose Dry Mouth Hearing Loss Others: Neurological Psychiatry & Musculoskeletal Headache Migraines Paralysis Fever Joint Ache Others: Respiratory Cough Bronchitis Shortness of Breath Asthma Emphysema COPD Others: Social History Current everyday smoker Current some day smoker Former smoker Never smoked Cigarettes Cigars Tobacco Other Please Circle and Fill in Blank Below: Frequency: Packs/Cigars per Day/Week/Month for Months/Years
6 Medications: No Medications By Mouth (Please List): Drug Allergies (Please List): Surgeries (Please List): _ Eye Drops (Please List): Eye Surgeries (Please List): Additional Information:
7 MEDICAL VS. VISION POLICY Patient Acct #: Date: Routine Vision (Refractive) Coverage: Your vision insurance (Eyemed or VSP) is intended to provide you with a baseline, routine eye evaluation and update your glasses prescription ONLY. If the doctor discovers any medical eye problem during a routine exam, the visit is now a medical exam and will be billed to your medical insurance. This is based solely on the reason for requesting the exam and the underlying diagnoses. Dr. Crandall is a Medical Doctor and Surgeon, and is trained to address your medical issues first and foremost, whether known or unknown before the exam. Your vision insurance is a supplemental insurance and secondary to your medical insurance. Patient Responsibilities: Since your medical insurance may be billed for the exam all applicable copays and deductibles apply. Please understand that each patient s insurance coverage varies and Crandall Eye Physicians and Surgeons cannot be held responsible for knowing every patient s coverage. Medical Eye Examination Coverage : If you have an eye condition or complaints such as but NOT limited to: Cataracts Macular Degeneration Glaucoma Dry Eyes Cornea Problems Diabetes High Blood Pressure Itching, Burning Eyes Headaches Flashes and Floaters Pink Eye Something in Eye Double vision Pain I understand that if ANY of the above conditions or complaints exist, this examination will be billed to my medical insurance. Patient or Guardian Signature Date Relationship if not signed by patient Thank you for trusting your eye health to us
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9 Elizabeth Crandall, MD Ophthalmology 136 W. Cherry St Jesup, GA Phone: (912) Fax: (912) NOTICE OF PRIVACY PRACTICES -- SUMMARY AND ACKNOWLEDGEMENT We will use and disclose your health information in order to: Treat you or assist other healthcare providers in treating you. Obtain payment for our services and to allow insurance companies to process claims for services rendered to you. Comply with quality assessments and licensing requirements. A written authorization will be requested to provide your private health information (PHI) for any reasons other than those stated above. As a patient you have the rights to: Have access to and/or a copy of your health information Receive an accounting of certain disclosures we have made of your PHI Request restrictions as to how your PHI is used or disclosed Request that we communicate with you in confidence Request that we amend your health information Receive notice of our privacy practices At any time you can request a copy of the full version of our privacy practices, please let a staff member know so that we can get that for you. If you have any questions about our privacy practices, please contact our Privacy Officer at the number below: Privacy Officer, Justin Crandall Phone number: (912) Fax number: (912) You have the right to file a complaint with us or with the Office for Civil Rights. We will not discriminate or retaliate in any way for this action. To file a complaint, please contact the applicable party: Office for Civil Rights I hereby understand that under the Health Insurance Portability & Accountability Act of 1996 ( HIPAA ), I have certain rights to privacy regarding my protected health information (PHI). I understand that my PHI will only be used for the reasons stated above, unless written notification is given. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. Patient or Guardian s Signature Date Printed Name
Immediate Family History Please list Father, Mother, Brother, Sister or Children
: Social Security # Name: of Birth: Age: Address: City: State: Zip: Home#: Cell#: Work#: E-mail: Status: Married Single Divorced Widowed Work Place/School: Occupation/Grade: Emergency Contact (Name/Phone):
- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )
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Patient: First M.I. Last Date of Birth: Address: City: State: Zip Code: Responsible Billing Party: Social Security #: DOB: Home Work: Mobile: Best Contact number for confirmation calls is: Email (Required):
Allergy & Asthma Consultants, L.L.P. 720 W. 34 th Street Suite 200 Austin, Texas Office (512) Fax (512) PATIENT INFORMATION
720 W. 34 th Street Suite 200 Austin, Texas 78705 Office (512) 454-5821 Fax (512) 459-9137 PATIENT INFORMATION MRN DR ENTERED VERIFIED Patient Information ( as it appears on insurance card) Last First
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD Phone: 706-850-8322 Fax: 706-850-8322 PATIENT HISTORY FORM Date of first appointment: / / Time of appointment: Birthdate: Name LAST FIRST MIDDLE INITIAL
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
PATIENT INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( ) May we contact you by ?
PATIENT INFORMATION date: Last Name First Name MI Address City State Zip Cell Phone _( ) Home Phone _( ) Email May we contact you by email? Yes No Date of Birth Age Marital Status Patient s Occupation
WELCOME TO FALLS CHIROPRACTIC AND INJURY!
WELCOME TO FALLS CHIROPRACTIC AND INJURY! PATIENT INFORMATION (Most of the information below is required for insurance purposes) DATE: / / FIRST NAME: M.I.: LAST NAME: DATE OF BIRTH: / / CALLED NAME /
Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Circle Preferred Phone Number Home
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
Patient Name (First, Middle, Last) Height Weight Date of Birth Social Security # Gender Male Female Ethnicity Race Language Address City State Zip Home Phone Cell Phone Work Phone Other Phone Email Occupation
Employer Work Phone ( ) Emergency Contact: Name Phone Relationship
Dr. Mrs. Ms. Mr. First Name M.I. Last Sex: M F SS# Date of Birth / / Age Marital Status: Married Single Divorced Widowed Mailing Address Email City State Zip Code Home Phone ( ) Alternate Phone ( ) Employer
Dear Patient, Norfolk Virginia Beach Chesapeake Suffolk Hampton Kilmarnock Portsmouth Eastern Shore Elizabeth City ALAN L. WAGNER, M.D. F.A.C.S.
ALAN L. WAGNER, M.D. F.A.C.S. KAPIL KAPOOR, M.D. DISEASES & SURGERY OF RETINA & VITREOUS MACULAR DEGENERATION DIABETIC RETINOPATHY RETINAL DETACHMENT ADULT & PEDIATRIC RETINAL SURGERY OCULAR ONCOLOGY /
Avery Acupuncture & Natural Medicine New Patient Registration
Welcome to Avery Acupuncture & Natural Medicine. Our goal is to make your experience here as comfortable as possible. If you have any questions, comments, concerns or suggestions, please let Veronica or
PATIENT REGISTRATION
PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:
New Patient Packet Patient Name: DOB: Age: Sex: Male / Female Height: Weight: PHYSICIAN CARE Primary Care Physician: Address: City: State: Zip: Phone: Fax: Referring Physician (if different from PCP):
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber