Low Vision Registration Form Name* Mr.Ms.MissDr. Prefix First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneDate of Birth* MM slash DD slash YYYY Social Security Number*(last 4 digits only) Age* Occupation Employer Race* American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian White Declined to Specify Other Race Ethnicity* Hispanic or Latino Not Hispanic or Latino Declined to Specify Language* English Spanish French Arabic Height*ft/in Weight*lbs How did you hear about us? Referral Others in Family Have Been in Online Insurance Provider List Other If someone referred you, please specify who: If other, please specify: Date of most recent eye examination MM slash DD slash YYYY Doctor who performed your most recent eye examination City and State of most recent eye examination Name of Primary Care Physician Last Exam Date MM slash DD slash YYYY Previous Eye CarePlease check all that apply Full time glasses Eye Surgery Eye Medications Low Vision Aid/Magnifiers currently used Previous Low Vision Evaluation If eye surgery, please specify the type of surgery: If eye medications, please list: If Low Vision Aid/Magnifiers are currently used, please specify: If Previous Low Vision Evaluation, please specify the date and place: Please check any of the following that apply to you: Double Vision Blurred Vision Eye Pain or discomfort Eye turns in or out Hold reading close Close, cover one eye Eyes frequently red Lost place when reading Make poor distance judgements Eye or health problems in family Bothered by light General Health Problems: Past severe head injury Thyroid problems Diabetes High or low blood pressure Headaches Allergies Sinus infections/pressure Cataracts Glaucoma Primary Insurance PlanName of Insurance Primary Insured Name First Last Relation to Patient Insured ID Number Group Plan Name/Number Secondary Insurance PlanName of Insurance Primary Insured Name First Last Relation to Patient Insured ID Number Group Plan Name/Number Please list any additional persons you authorize to access your personal health information (PHI), including billing and medical records information:Full NameRelationship Payment is due at the time services are rendered.I will be paying today by: Cash Check Credit/Debit Card (we accept Visa, Mastercard, American Express) Care Credit If you have insurance coverage for these services or materials and we are current providers, we will submit claims for you. However, we are not liable for collecting your claim. After 30 days, we will expect payment in full from you if your insurance company has not paid. I hereby authorize my insurance carrier to make payment directly to Five Points Eye Care Center. I authorize that I am financially responsible for all charges whether or not they are covered by insurance or other entities. I also authorize release of any information regarding my treatment or condition in order to obtain payment for services. I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any services rendered. I have read all the information on this sheet and have completed the above questionnaire. I certify that this information is true and correct to the best of my knowledge. I agree to notify this office of any changes in my insurance status or the above information.Patient Signature*Date* MM slash DD slash YYYY Parent/Guardian Signature (if minor)Date MM slash DD slash YYYY