SQUINT OPTOMETRY
PATIENT REGISTRATION FORM
This form is transmitted via a secure, hipaa compliant link

Patient Information

Last Name First Name MI Preferred Name/Pronoun

Date of Birth Sex: M F Email

Address City Zip

Home Phone Cell Phone Work Phone

Employer/school Occupation

Marital Status Minor Married Single Divorced Widowed Other

Last exam

Current Medications None

Allergies to medications None

How did you hear about us

Routine Vision Coverage

(We accept VSP and certain Metlife Vision and Guardian Vision plans)

Insurance Company Name ID# or SS#

Subscriber Name Relationship to patient

Subscriber DOB (if different from above)

Medical Insurance Information

(We accept Medicare)

Insurance Company Name Subscriber ID#

Subscriber Name Relationship to patient

Subscriber DOB (if different from above)

WHAT ARE THE REASONS FOR YOUR APPOINTMENT? (Please check ALL that apply)

Routine eye exam	First time contact lens fitting**	Dry or burning eyes
Need new glasses	Seeing flashes or floaters	Eye pain or red eyes
Need new contacts**	Eye itching or allergies	Interest in LASIK/PRK
Other or explanation
**I understand that contact lens professional fees are separate from the routine eye exam.

CHECK ANY MEDICAL CONDITIONS THAT APPLY TO YOU, or check None:

None

Diabetes	Pregnant	Migraines/Headaches	Depression/Anxiety
High blood pressure	Nursing	Cancer	Seasonal allergies
High cholesterol	Arthritis	Thyroid disease
Other or explanation

CHECK ANY EYE CONDITIONS THAT APPLY TO YOU, or check None:

None

Glaucoma	Macular degeneration	Turned/Lazy eye	Eye injury/Surgery
Cataracts	Retinal detachment	Dry eye	Eye Allergies
Floaters	Keratoconus
Other or explanation

CHECK ANY EYE CONDITIONS PRESENT IN FAMILY MEMBERS (please state relationship or check None)

None

Glaucoma		Macular degeneration
Cataracts		Retinal detachment
Retina disease		Adopted/Unknown
Other or explanation

EYEWEAR QUESTIONNAIRE

Do you wear glasses? Yes No
If yes: Distance Reading Computer Progressive

If yes: Wear all the time Wear sometimes

Do you wear contact lenses Yes No
If yes:

	Type or brand of contacts
	How often do you wear contacts?
	Daily A few times a week A few times a month Other
	How often do you change or discard your contacts?
	Daily Weekly Monthly Other

Do you have problems with your current glasses/contacts?

AUTHORIZATION

I hereby authorize Squint Optometry to apply for benefits on my behalf for covered services rendered by them. I request payment to be made directly to their office.
I understand that I am financially responsible for the charges not covered by my insurance company, including based on my failure to obtain a referral or meet a deductible. I certify that the information I have reported is correct and further authorize the release of any information, including medical information, for this or any related claim. This authorization may be revoked by me at any time in writing.

I also acknowledge that I have been provided access to SQUINT OPTOMETRY's Hipaa Privacy Notice and the opportunity to read and ask questions about it. [Click here for Squint's Hipaa Privacy Notice]

Signature of Patient, Parent or Guardian: / /
Date: