Patient Registration Form - Hopewell Eyecare - Dr. Francis A. Tarantino, Optometrist

WELCOME TO OUR OFFICE
Patient Registration Form

If you would like to make an appointment with our office, you can expedite your visit by completing the patient registration and insurance form. Either bring it with you on the day of your visit or fax the form to us at (845) 226-1464. If you wish to inquire whether we are participating with your particular insurance and you cannot find our name in your provider manual, please call our office with the telephone number of your insurance. We will inquire further for you.

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Date of Appointment
E-Mail Address
Who may we thank for referring you
Patient's Name		Date of Birth:
Address		State Zip
City		Work Phone
Home Phone		Soc. Sec.#
Occupation		Employer
Name of Parent or Spouse		Date of Birth:
Address		State Zip
City		Work Phone
Health Insurance/HMO Carrier ID#
Vision Plan Carrier Your Union?
Patient's Health History:
Date of last eye exam		By Whom
Your chief Complaint/or Problem
Concerning your health, do you have: allergies diabetes high blood pressure heart disease headaches pulmonary disease eye disease glaucoma other
Concerning your family history, is there a history of: diabetes high blood pressure glaucoma macular degeneration eye disease If so, what
Family physician		Address
Are you being treated for any medical conditions now? Yes No
If so, what
Last general physical exam Do you take medications? Yes No If so, list below:
MEDS
Patient's Ocular History
Do you have any problems with your present spectacle/or contact lens prescription? Yes No
Do you experience any: itching pain double vision spots light flashes
Have you ever worn contacts? Yes No
Eye color		Has your color vision been tested? Yes No
Is there a family history of an eye turn or "lazy" eye Yes No
Ever have an eye injury? Yes No Ever have eye surgery? Yes No
If so, what
Ever have vision training, eye exercises, or worn a patch over an eye? Yes No
OUR VISION/HEALTH INSURANCE POLICY: Our office accepts payment from various insurance companies and third party carriers for the convenience of our patients. Our policy is to bill your insurance carrier first. You will be responsible for whatever portion of your bill that is not paid by your insurance carrier. Patients who do not have coverage for materials must pay a deposit when the initial order is placed and the balance upon dispensing. Medicare patients are responsible for their annual deductible and 20% of the Medicare approved charges.
DO I NEED TO HAVE MY EYES DILATED? On the patient's first visit, a comprehensive eye exam many times will include pupillary dilation. This is used not only to determine the health of the eyes but the health of the patient. Pupillary dilation allows viewing the internal eye in great detail and permits the doctor to discover early detection of potentially serious eye health problems such as glaucoma, cataracts, and vascular disease. The procedure can also reveal any potentially damaging diseases such as diabetes, hypertension, drug toxicity, tumors and neurological disease. The eye drops will dilate the pupils and will cause some sensitivity to light and some mild blurring of vision. The symptoms typically last 3 to 4 hours. You will be given a tinted shield to wear when you leave to help you cope with the light. It is extremely important to inform us of your medical history and ocular symptoms. Some insurance plans cover this procedure while others may not. We may be able to inform you of this after we review your coverage and your file. I have read the above and (wish do not wish ) to have my eyes dilated. Patient signature
ABOUT THE "GLAUCOMA TEST" This office does not use an air-puff tonometer to determine the eye's pressure, so r..e..l..a..x. We use the Goldmann tonometer which is the standard by which all others are made. A yellow drop will be instilled which not only contains the fluorescein dye but also a topical anesthetic, so you will not feel anything.......as long as you keep your eyes open during the actual measurement. We normally begin testing at age 18 unless the family history suggests otherwise.

, Dr. Vernon Peryea