Patient Registration Form Millard Vision Center 15340 Weir Street Omaha, Nebraska 68137 Phone: 402-932-9222 www.millardvisioncenter.com Welcome to our office. Please complete this form to the best of your knowledge. The information you give will enable us to provide you with total eye care for you and your family.GENERAL INFORMATIONToday's Date MM slash DD slash YYYY Patient Name: Mr.Mrs.MissDr. Prefix First Last Gender:--Choose a Selection--FemaleMaleHow do you wish to be addressed? Social Security # 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 Birth Date: MM slash DD slash YYYY Home Phone:Cell Phone:Race--Choose a Selection--UnknownAfrican AmericanArabAsianCaucasianHawaiianHispanic/LatinoMultiracialAmerican IndianOccupation Employer Work Phone:Last Eye Exam MM slash DD slash YYYY Your Medical Doctor Previous Eye Exam Doctor BILLING INFORMATION (if different from patient )Name of person responsible for Account First Last Relationship to patient Social Security # Date of Birth MM slash DD slash YYYY Home Phone:Cell Phone:Home 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 INSURANCEVision Insurance Company Policy Holder ID# Medical Insurance Company Policy Holder ID# I do hereby authorize the release of any medical information necessary to process all claims, and request payment of any medical benefit be paid to Millard Vision Center. I have received the form “Joint Notice of Privacy Practices” and give my permission to MILLARD VISION CENTER to use and disclose my health information in accordance with the notice provided.Signature of Patient or Patient RepresentativeDate MM slash DD slash YYYY Relationship to PatientMotherFatherEmail AddressYour email is just for Millard Vision Center use, it will never be distributed to anyone. Who can we thank for referring you? MEDICAL HISTORYList any medications you take and dosage (including prescription, over the counter, and eye medications):MedicationDosage Do you have any allergies to medications? No Yes If yes, which medications? Do you have any other allergies? No Yes If yes, please list Latex sensitivity? No Yes List surgeries, hospitalizations and/or injuries you have hadAre you pregnant? No Yes Do you wear glasses? No Yes Do you wear contact lenses ? No Yes If yes, what brand? CARDIOVASCULARNoYesHeart DiseaseCongestive Heart FailureVascular DiseaseStrokeHigh Blood PressureMUSCULOSKELETALNoYesOsteoporosisArthritisChronic Low Back PainFibromyalgiaALLERGIC/IMMUNOLOGICNoYesSeasonal AllergiesSjogren's DiseaseHIV/AIDSLupusRESPIRATORYNoYesSleep ApneaBronchitisAsthmaEmphysemaINTEGUMENTARYNoYesRosaceaShinglesEczemaCold SoresPsoriasisSkin CancerNEUROLOGICALNoYesHeadachesSeizuresDizziness / VertigoMultiple SclerosisGASTROINTESTINALNoYesCrohn's DiseaseCeliac DiseaseColitisUlcerENDOCRINENoYesDiabetesThyroid DysfunctionHepatitisPSYCHIATRICNoYesDrug AddictionAlcohol AddictionDepressionGENITOURINARYNoYesHerpesProstate Disease/CancerKidney DiseaseHEMATAOLOGICAL/LYMPHATICNoYesBleeding problemsAnemiaLeukemia/LymphomaJaundiceSOCIAL HISTORYNoYesDo you use alcoholTobacco user?--Choose a Selection--CurrentPreviousNeverIf current--Choose a Selection--Former smokerHeavy tobacco smokerLight tobacco smokerNever smokedSmoker current status unknownUnknown if ever smokedType--Choose a Selection--CigarsCigarettesSmoklessTobaccoVapesE-CigarettesFAMILY HISTORYPlease note any family (parents, grandparents, siblings, children, living or deceased) for the following conditions:SYSTEMICNoYesCancerDiabetesHigh Blood PressureRheumatoid ArthritisHeart DiseaseThyroid DiseaseStrokeOCULARNoYesCataractsMacular DegenerationGlaucomaCross Eye/Lazy EyeAmblyopiaRetinal DetachmentBlindnessIf you selected "yes" for any of the above, please specify:ConditionRelationship If you selected "yes" for any of the above, please specify:ConditionRelationship THANK YOU FOR CHOOSING MILLARD VISION CENTER !
