Welcome to Our Office SS or ID#*Member’s Name Name* First Last Male Female N/A Date of Birth* MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Occupation Cell Phone*Work PhoneEmail* Child Parent’s Name How did you hear about our office? Employer Method of Payment Cash MC Visa Discover (signature of credit cards must match the payee)Vision Insurance Yes No (if yes) Medical Insurance Yes No (if yes) Patient HistoryPlease complete all information.Date of last eye exam MM slash DD slash YYYY by Dr. Name of Primary Physician Date of last medical exam MM slash DD slash YYYY Please list all current medications Please list all allergies to medications Please list all major injuries, surgeries, or hospitalizations Are you currently pregnant or nursing Ocular HistoryPlease check all conditions that apply (for relatives, please indicate who, blood relatives only)SELF Blurred Vision Itchy Eyes Frequent Headaches Double Vision Eye Turn/Lazy Eye Night Vision Issues/Glare Dryness of Eye Mucous Discharge Pain in/around Eyes Floaters (“black spots”) Flashes (“lightning streaks”) Eyes Burn Eyes Water Past Eye infection Past Eye Surgeries Past Eye Injuries SELF Glaucoma Cataracts Macular Degeneration Retinal Detachment Cornea problems Blindness High Blood Pressure Diabetes High Cholesterol Heart Disease Asthma Thyroid Problems Arthritis Kidney Problems Lupus Cancer (type) RELATIVE Glaucoma Cataracts Macular Degeneration Retinal Detachment Cornea problems Blindness High Blood Pressure Diabetes High Cholesterol Heart Disease Asthma Thyroid Problems Arthritis Kidney Problems Lupus Cancer (type) for relatives, please indicate who Cancer - type Cancer - type SOCIAL HISTORYDo you currentlyUse Tobacco Yes No Drink Alcohol Yes No Use Rec. Drugs Yes No Infection Exposure Yes No Glasses History Wear glasses now? Yes No Worn in the past? Yes No Age of current glasses Used for distance near both Remarks Contact Lens History(check all that apply)Have you worn contacts? Yes No Do you currently wear contacts? Yes No How old is the pair you are wearing? Type of Lenses SOFT HARD/GP ASTIGMATISM/TORIC BIFOCAL MONO How often do you sleep in you contacts? Wear Schedule ONE-DAY 2-WEEK MONTHLY QUARTERLY YEARLY How often do you replace your contacts? What brand of contacts do you wear? Current cleaning solution brand? How any hours of wear time per day?SPECIALTY TESTING is available and may be needed based on the discretion of the Optometric Doctor. Additional testing requires more time than the normal vision and eye healthy exam and may be scheduled later. Fees will vary depending on the testing. Signature*Date MM slash DD slash YYYY PATIENT CONSENT FORMI understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have certain rights regarding my protected health information. I understand that this information can and will be used to: Conduct. Plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. I have received read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at any time to obtain a current copy I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment or payment. I also understand you are not required to agree to requested restrictions, but if you do agree, then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient Name Relationship to Patient Signature*Date MM slash DD slash YYYY FINANCIAL RESPONSIBILITY STATEMENTWe will be happy to help you file your insurance claim forms or take assignment on your vision/medical benefit as designated by (name of insurance company) under (primary member’s name) This will be provided without additional charge to you. We will also do all that we can to help you receive maximum benefits. In the event that the Plan Sponsor determines that you are not eligible at the time of service, or makes a determination that you are eligible for a reduced level of coverage, by signing this statement you do hereby agree to be financially responsible for any deductibles, co-payments, and co-insurances incurred at the time of the visit. I understand that the nature of my eye appointment, ocular and medical history and ultimate diagnosis/es will be used to determine which medical and/ or vision plans will be billed. If left unsigned, you will be responsible for full payment of services rendered at the time of service at our usual and customary fee levels. I understand that if, for ANY REASON, payment for provided services and/or products is denied to Dr. A. Joshi & Associates, Optometrists, PA. by my third part insurance, I am responsible for payment of provided services and/or products that were denied by insurance and payment will be expected within 30 days of receipt of this bill Signature (Patient/Guarantor)Date MM slash DD slash YYYY
