PATIENT REGISTRATION FORM
PATIENT INFORMATION
PATIENT NAME First Middle Last DATE OF BIRTH MAILING ADDRESS /PO BOX APT. NO. CITY SOCIAL SECURITY NO. MARITAL STATUS S M D W HOME NUMBER SEX M F STATE ALTERNATE NUMBER CELL WORK ZIP SPOUSE’S NAME EMAIL ADDRESS OCCUPATION EMPLOYER PRIMARY CARE PHYSICIAN REFERRED BY NAME OF LAST EYE DOCTOR DATE OF LAST EYE EXAM EMERGENCY CONTACT AGE RELATIONSHIP PHONE NUMBER INSURANCE INFORMATION
PRIMARY INSURANCE POLICY HOLDER NAME POLICY # GROUP # EFFECTIVE DATE POLICY HOLDER DATE OF BIRTH POLICY HOLDER SOCIAL SECURITY NO. RELATIONSHIP TO PATIENT POLICY HOLDER ADDRESS POLICY HOLDER PHONE NUMBER SECONDARY INSURANCE POLICY HOLDER NAME POLICY # GROUP # EFFECTIVE DATE POLICY HOLDER DATE OF BIRTH POLICY HOLDER SOCIAL SECURITY NO. RELATIONSHIP TO PATIENT POLICY HOLDER ADDRESS POLICY HOLDER PHONE NUMBER WORKERS COMP.
CLAIM # WORKMANS COMP. INSURANCE & ADDRESS EMPLOYEER’S ADDRESS ADD’L INFO.
DID YOU SUSTAIN INJURY AT WORK? ( ) Y ( ) N DATE OF INJURY HAVE YOU MADE ANY CHANGES TO YOUR CHOICE OF INSURANCE OPTIONS IN THE LAST OPEN ENROLLMENT PERIOD?( ) Y ( ) N I DO NOT HAVE HEALTH INSURANCE __________ INITIALS FOR MINORS ONLY: PARENTS/GUARANTOR’S NAME PARENTS/GUARANTOR’S DATE OF BIRTH EMPLOYEER’S PHONE NUMBER I authorize and request that payments under my insurance program be made directly to Patrick D. Aiello M.D. LLC for the
services furnished to me. I also authorize Patrick D. Aiello M.D. LLC to release information needed for treatment, payment of
claims and healthcare operations. I further permit copies of this authorization to be used in place of the original. I do realize
that there will be a portion of the bill that is not covered by my medical insurance of which is my responsibility and I do agree
to pay in full my obligation at the time/day services are rendered. I understand and agree, should my account be turned over
to a collection agency, I will be responsible for collection fees up to 50% of the outstanding balance. I also understand and
agree that should a suit be brought against me, I will pay court costs and attorney fees.
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SIGNATURE OF PATIENT/ LEGAL GUARDIAN
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DATE
I acknowledge I have received a copy of this office’s NOTICE OF PRIVACY PRACTICES.
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SIGNATURE OF PATIENT/ LEGAL GUARDIAN
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DATE
Ocular History Please circle any disease or surgeries that you have been treated for in the past. Cataracts / Macular Degeneration / Glaucoma / Retinal Detachment / Iritis / Uveitis Ocular Surgeries: Cataract / Retinal / Glaucoma / Muscle / Lid / Refractive / Cornea Ocular Medications: Ocular Injuries: Family History Please circle any of the health problems that any immediate family member has. Diabetes / High Blood Pressure / Heart / Lung / Stroke / Cancer / Glaucoma / Macular Degeneration / Social History Do you smoke or chew tobacco? YES / NO How many cigarettes per day? ____ YES / NO How much per day? ____ YES / NO Do you drink alcohol? Do you use any illicit drugs? Medications: (Please list all medications you are presently taking) Please list any medications that have caused adverse or allergic reactions. None known Authorized individuals to discuss your eye health with: PREFERRED PHARMACY: CONSTITUTIONAL Fever, Weight Loss / Gain CARDIOVASCULAR Hypertension Heart Attack (MI) Cholesterol Congestive Heart Failure Coronary Artery Disease Aneurysms Arrhythmias GASTROINTESTINAL Ulcers Bowel Disorders Reflux Disease Diverticulitis Cancer INTEGUMENTARY Skin Cancer Psoriasis Rosacea NEUROLOGICAL Multiple Sclerosis Alzheimer’s Stroke Parkinson's Headaches Muscular Dystrophy YES ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ IMMUNOLOGY HIV AIDS EARS / NOSE / THROAT Sinusitis Ear Infection Allergies RESPIRATORY Emphysema Bronchitis Asthma COPD Lung Cancer Pneumonia MUSCULOSKELETAL Arthritis Osteoporosis Gout TMJ ENDOCRINE Diabetes Thyroid Pituitary YES ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ HEMATOLOGIC / LYMPHATIC Anemia Leukemia Lymphoma GENITOURINARY Renal Failure Urinary Tract Infection Sexually Transmitted Disease Nephritis Prostate Cancer Ovarian Cancer PSYCHIATRIC Depression Drug Dependence Panic Disorder Alcoholism OTHER YES ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____