Patient Registration Form "*" indicates required fields Patient Registration FormSelect Your Location Kingsport Johnson City Bristol Turkey Creek Westtown Harvest Park Chattanooga Northgate Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Gender* Female Male Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number*Please provide a telephone number, with area code, so we can contact you.Cell PhoneDate of Birth* MM slash DD slash YYYY Social Security Number Occupation Employer Email Address Due to new healthcare regulations involving healthcare portals and meaningful use of patient records, we need an email address on file.Marital Status Single Married Health Insurance Carrier Vision Insurance Carrier Have You ever been to this office before? Yes No When was your last Eye Examination? Eye Health / HistoryPlease check all that applyWhat Problems are you currently having? Blurred Vision Halos/ Glare Flashes/ Floating spots Redness Burning Itching Dryness Double Vision Discharge Headaches Watering Foreign Body sensation Pain/Soreness Contact Lens Problems Peripheral Vision Loss Other Other Have you ever been told you have any of these or have any family history of these? Cataracts Dry Eye Third Choice Lazy eye Glaucoma Macular Degeneration Crossed eyes Retinal Detachment Retinitis Pigmentosa Blindness Melanoma of Eye Corneal Dystrophy Other Please check all that applyOther Do you now wear contact lenses? Yes No If no, have you worn them in the past? Yes No Are you Interested in Contact lenses even for occasional use? Yes No Are you Interested in LASIK Yes No Have You ever had an Eye injury, surgery or bad infection? Yes No Explain DILATION INFORMED CONSENT Dilation is recommended every 2-3 years, even in healthy eyes. Dilation may be required more frequently by your eye doctor for many ocular and systemic conditions. Many serious and sometimes vision threatening conditions cannot be accurately diagnosed or detected without dilation. Dilation will make you light sensitive, and will make your distance and reading vision blurry. Driving is usually safe when dilated, and the patient assumes all risk of operating a motor vehicle, as well as any other visually demanding tasks, while dilated.DO YOU WISH TO BE DILATED TODAY? Yes No If Necessary Medical HistoryPlease Check all that apply to you, circle if Family History onlyApproximate Height Approximate Weight Please check off all that apply to you Sinus Congestion Hearing Loss Multiple Sclerosis Cerebral palsy Parkinson’s Migraines Stroke Depression Anxiety Bipolar Disorder Heart disease Artery disease Hypertension High Cholesterol Asthma COPD Colitis Crohn’s Disease Ulcers Currently Pregnant Degenerative Disk Muscular Dystrophy Fibromyalgia Osteoporosis Rosacea Shingles Diabetes Type 1 Diabetes Type 2 Thyroid disease Rheumatoid arthritis Lupus Sjogren’s disease HIV/AIDS Smoker Consume Alcohol Other Other MedicationsPlease list any current Medications you take, if you do not know the name- then what you take it forPlease list any current Medications you take Add Removeif you do not know the name- then what you take it forAre allergic to any medications? Yes No Please List Are there any other conditions we should Know about? Yes No Explain DR. TORREY J. CARLSON & ASSOCIATES, P.C. HIPAA PRIVACY * I acknowledge and agree that I have been informed that this office abides by the HIPAA laws and am entitled to a copy of the Notice of Privacy Practices for review and, if desired, to keep for my records on the date identified below.*Consent 2* I understand that the Office may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit the Office to perform its administrative duties, provide me with eye care services and products, process my vision/medical benefits claims and communicate with me regarding vision care services/products provided by the Office (for example, mailings of exam reminders or information about services/products provided by the Offices).*Consent 3* I can be assured that this Office does not sell my personal health information of any kind to a third party for such party’s own use. I authorize the Office to submit my vision/medical benefits claims to my plan sponsor or health plan to receive reimbursement directly for the vision services and products that I have received from the Office.*Patient SignaturePatient’s Legal Representative Date MM slash DD slash YYYY Consent* I authorize Dr. Torrey J. Carlson & Associates to release my complete medical records and other documentation made by doctors or personnel for the entire time I was treated by the Practice to the following family members, friends or other care givers who contact us for purposes of providing them with information related to my treatment and/or payment obligations:*NameRelationship Add RemoveConsent* I understand the practice may need to contact me for purposes related to my treatment such as; related to my treatment, appointments, referrals, and billing business.*My preferred method of communication is: Phone/text (voice messages may be left) Email Postcard Any of the above Patient SignaturePatient’s Legal Representative Date MM slash DD slash YYYY Consent* I hereby authorize the use of my above email or address . I understand I can revoke this authorization at any time and the au*Insurance/ Medicare ReleaseConsent* I authorize the release of any information required to process an insurance claim. I understand that I am responsible for payment of any amounts not covered by my insurance plan. By signing below, I submit all health information disclosed is accurate. I authorize the Office to receive insurance payments directly for the services I have received.*Patient SignaturePatient’s Legal Representative Date MM slash DD slash YYYY Email Address Due to new healthcare regulations involving healthcare portals and meaningful use of patient records, we need an email address on file.CommentsThis field is for validation purposes and should be left unchanged.
