Patient Registration
Today's date: _____________
Patient Information
MI
First Name
Last Name
Address
City
State
Zip
Please check Primary form of
contact:
Other Name(s) Used
Home Phone
Work Phone
Cell Phone
M
Gender
F
E-mail Address
SSN
Marital Status
o
o
o
o
o
o
Preferred Language
Preferred Contact
Which form of communication
do you approve for us to
contact you?
Married
Single
o
o
o
o
o
Divorced
Separated
Widowed
Life Partner
Date of Birth
Mail
Who referred you
Ethnicity
o
o
o
Home Phone
Hispanic/Latino
Non-Hispanic
unknown/or decline to
answer
Day Phone
Cell Phone
Race
o
o
o
o
o
o
Patient Portal (MyChart)
American Indian or Alaskan
Native
Asian
Black or African American
Native Hawaiian/Other Pacific
Islander
White
Other (decline to answer)
Primary Care Provider name
Referring Provider name
Cardiologist name
Endocrinologist Provider name
Address
Address
Address
Address
Responsible Party (Guarantor)
Last Name
MI
First Name
Same as patient
Date of Birth
Address
City
State
Zip
Please check Primary form of
contact:
SSN
Home Phone
Work Phone
Cell Phone
Relationship to Patient
Preferred Language
Driver’s License
First Name
Emergency Contact (for minor child, this section may be used for other parent)
Last Name
MI
Date of Birth
Address
City
State
Zip
Please check Primary Phone
Home Phone
Work Phone
Cell Phone
Primary insurance
Insurance information (Please complete all details)
ID # and Group #
DOB
Subscriber and relationship
Secondary insurance
ID # and Group #
Subscriber and relationship
DOB
I/We do hereby consent to and authorize the performance of all medical services and treatments deemed advisable by the physicians and staff of
Mid Atlantic Retina (MAR) to me or to the above-named minor of whom I am the parent or legal guardian. I hereby certify that, to the best of my
knowledge, all statements contained herein are true. I understand that, although the providers of MAR may or may not participate with my
insurance carrier(s), I am financially responsible for any co-payments, deductibles, and payment for non-covered services or out of network
services incurred for myself and/or my dependent(s). I furthermore agree to pay accrued interest, if applicable, collection expenses, and
reasonable attorneys’ fees incurred to collect any amount I may owe. I also hereby authorize MAR to release information as necessary for and/or
requested by the insurance company and/or its representatives for claims processing and payment. I fully understand this agreement and
consent will continue until cancelled by me in writing.
Signature of Patient/Responsible Party
Date
Name of Patient/Responsible Party (Please Print)
Relationship to Patient
Name: _
DOB:
__________
Pharmacy Information
Preferred Pharmacy
Secondary Pharmacy
Name
Name
Address
Address
Phone
Phone
Fax
Fax
Advanced Directives
Durable
Power of Attorney
Living Will
Date Reviewed:
Medications – List all medications you take, prescription and non-prescription, and the dosage
I do not take any medications
None
Do Not Resuscitate
Medication Name
HC Proxy
Dosage/strength
Medication and Food Allergies – List all known allergies (drugs, food, animals, etc.)
No Known Allergies
Family History – Check if any family member(s) has had any of the following conditions.
Adopted
Diagnosis
Anemia
Arthritis
Blindness
Cancer (type)
Cataract
Diabetes
Diabetic Retinopathy
Glaucoma
Heart Disease
Hepatitis
Hypertension
Kidney Disease
Macular Degeneration
Retinal Detachment
Stroke
Tuberculosis
Thyroid Disease
Uveitis
Mother
Father
Brother
Sister
Other
Other
Other
Name: _
DOB:
__________
Medical History – Check if you have ever experienced the following conditions, and year of onset.
Condition
Year
o None
o Alzheimers
o Anemia
o Arthritis
o Asthma
o Blood Clots
o Bronchitis
o Cancer – Type
o Cardiovascular Disease
o Depression
o Diabetes (see questions below)
o Diverticulitis
o Emphysema
o Hearing Loss
o Heart Attack
o Heart Murmur
o Hepatitis
o HIV
o Hypercholesterolemia
o Hypertension
o Irregular Heart Beat
o Juvenile Rheumatoid Arthritis
o Keloid scarring
o Kidney Infections
o Lupus
o Lyme Disease
o Mania/Bipolar
Diabetes/when diagnosed?
Diabetes
Recent Range: From
Yes
No
Year
o Marfan's Syndrome
o Migraines
o Mitral Valve Prolapse
o Multiple Sclerosis
o Myasthenia Gravis
o Neurofibromatosis
o Osteoporosis
o Psychosis
o Sarcoidosis_
o Schizophrenia
o Seizure
o Sinusitis
o Sjogren's Syndrome
o Skin Cancer
o Steroid Therapy (long term)
o Stevens-Johnson Syndrome
o Stickler Syndrome
o Stroke
o Thyroid condition
o Temporal Arteritis
o Tuberculosis
o Ulcers
o Urinary Infections
o Von Hippel-Lindau Syndrome
o Other
Are you on insulin?
What is Hgb A1C?
Are you on dialysis?
Condition
to
Yes
No
X per day
__
Do you test at home?
Yes
No
Name: _
Y
Y
Y
Y
N
N
N
N
DOB:
Glaucoma
Macular Degeneration
Diabetic Retinopathy
Other
__________
Please list any prior eye problems & treatments:
treatment:
treatment:
treatment:
treatment:
Surgical History – Check if you have received the following procedures, and year performed.
Surgical Procedure
Date
Cataract Surgery
Date
Right eye
Left eye
Retinal Surgery
Right Eye
Left Eye
Social History
Marital Status: □ Married □ Single □ Widow/Widower □ Divorced □ Separated
Do you smoke cigarettes/cigars? □ yes □ no
Do you drink alcohol? □ yes □ no
Number per day:______ Years Smoked:_____ Year quit: _______
How much? _________________ How often?__________
Past and present drug use (legal or illegal) is important for drug and anesthetic interactions.
aware of this: □ yes □ no
What is your occupation? _______________________
Please indicate if we need to be
Are you still working? □ yes □ no
Have you had a blood transfusion since 1977? □ yes □ no When?_________________
Living Conditions: □ alone
□ nursing home
□ caretaker/family
□ other______________
Do you have or have you ever had any pets? □ yes □ no What kind?___________________
Do you exercise? □ yes □ no What kind?___________________ How often?___________
Review of Systems (check all that apply)
Constitutional
Cardiovascular
Endocrine
Gastrointestinal
□ Jaw Pain
□ Fever
□ Weight Loss
□ Fatigue
□ Loss of Appetite
□ Trouble Sleeping
□ Other
□ Chest Pain
□ Swelling of Feet
□ Excessive Thirst
□ Excessive Urination
□ Cold Intolerance
□ Heat Intolerance
□ Other
□ Abdominal Pain
□ Nausea
□ Diarrhea
□ Constipation
□ Other
Hent
Neurologic
Genitourinary
Integumentary
□ Hearing Loss
□ Sore Throat
□ Runny Nose
□ Other
□ Weakness
□ Headaches
□ Scalp Tenderness
□ Dizziness
□ Paralysis of Extremities
□ Tremor
□ Pain/Burning with Urination
□ Other
□ Rash
□ Change in Mole
Respiratory
Hematology / Oncology
Musculoskeletal
□ Wheezing
□ Cough
□ Shortness of Breath
□ Other
□ Easy Bruising
□ Prolonged Bleeding
□ Clotting Problems
□ Other
□ Muscle Aches
□ Joint Pain
□ Difficulty Laying Flat from
Muscular Discomfort