MIDZ04 Patient Registration

Patient Registration

Patient Information

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Primary form of contact *

Home Phone

Work Phone

Cell Phone

Home Phone Number *

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Email - if you do not have an email, please type NA *

Gender *

Male

Female

Social Security Number

Preferred Language *

Marital Status *

Married

Single

Divorced

Separated

Widowed

Life Partner

Domestic Partner

Which form of communication do you approve for us to contact you?

Mail

Home Phone

Day Phone

Cell Phone

Patient Portal

Ethnicity *

Hispanic/Latino

Non-Hispanic/Latino

Unknown or decline to answer

Race *

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian/Other Pacific Islander

White

Other (decline to answer)

Primary Care Provider Name *

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Referring Provider Name *

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Endocrinologist Provider Name

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Responsible Party (Guarantor)

Responsible Party (Guarantor) *

Same as patient

Other - Please fill out below

Name

First Name

Middle Name

Last Name

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Primary form of contact

Home Phone

Work Phone

Cell Phone

Home Phone Number

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Social Security Number

Relationship to Patient

Emergency Contact (for minor child, this section may be used for other parent)

Name

First Name

Middle Name

Last Name

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Primary form of contact

Home Phone

Work Phone

Cell Phone

Home Phone Number

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Relationship to Patient

Insurance information (Please complete all details)

Are you self pay? *

Yes

Are you the subscriber?

Yes

Primary Insurance Company *

Subscriber's Name

First Name

Last Name

Do you currently have a copy of your primary insurance card with you now? *

Yes

Please attach a photo of the FRONT side of your PRIMARY insurance card. You can use your cell phone to take the picture. * (REQUIRED)

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

The lens/flash needs to be top left. (Take picture in landscape form)

Please attach a photo of the BACK side of your PRIMARY insurance card. You can use your cell phone to take the picture. * (REQUIRED)

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

The lens/flash needs to be top left. (Take picture in landscape form)

Do you have secondary insurance *

Yes - please complete information below

Are you the subscriber?

Yes

Secondary Insurance Company

Subscriber's Name

First Name

Last Name

Please attach a photo of the FRONT side of your SECONDARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

The lens/flash needs to be top left. (Take picture in landscape form)

Please attach a photo of the BACK side of your SECONDARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

The lens/flash needs to be top left. (Take picture in landscape form)

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.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Name of Patient/Responsible Party *

First Name

Last Name

Relationship to Patient

Check if you have ever experienced the following conditions, and year of onset.

	Check all that apply	Year	Details
None
Alzheimers
Amputation (State location in Details column)
Anemia
Arthritis (State location in Details column)
Rheumatoid Arthritis (State location in Details column)
Asthma
Atrial Fibrillation
Blood Clots
Bronchitis
Cancer - (State type in Details column)
Cardiovascular Disease
COPD
Crohn's Disease
Depression
Diabetes (see questions below)
Diverticulitis
Emphysema
ESRD
Hearing Loss
Heart Attack
Heart Murmur
Hepatitis A
Hepatitis B
Hepatitis C
HIV
Hypercholesterolemia
Hypertension
Irregular Heart Beat
Juvenile Rheumatoid Arthritis (State location in Details column)
Kidney Disease Stage 1
Kidney Disease Stage 2
Kidney Disease Stage 3
Kidney Disease Stage 4
Kidney Disease Stage 5
Lupus
Lyme Disease
Lyme Disease with Arthritis
Mania/Bipolar
Marfan's Syndrome
Migraines
Mitral Valve Proplapse
Multiple Sclerosis
Myasthenia Gravis
Neurofibromatosis Type 1
Neurofibromatosis Type 2
Osteoporosis
Psychosis
Sarcoidosis - Lung
Sarcoidosis - Lymph Node
Sarcoidosis - Lung & Lymph Nodes
Sarcoidosis - Other (State in Details column)
Schizophrenia
Seizure
Sickle Cell Anemia
Sickle Cell Hb-C
Sinusitis
Sjogren's Syndrome
Steroid Therapy (long term)
Stevens-Johnson Syndrome
Stickler Syndrome
Stroke
Thyroid condition
Temporal Arteritis
Transplant Recipient - Kidney
Transplant Recipient - Heart
Transplant Recipient - Bone Marrow
Transplant Recipient - Pancreatic
Transplant Recipient - Other (State in Details column)
Tuberculosis
Ulcerative Colitis
Ulcers
Urinary Infections
Von Hippel-Lindau Syndrome
Other - state in Details column

Do you have diabetes? *

Yes

Are you on insulin?

YES

If yes, number of time per day

Recent range: From - To

Do you test at home?

Yes

Are you on dialysis?

Yes

Frequency? Times/week

Vaccines Received

Please list any prior eye problems & treatments:

Surgical History

Non-Ocular Surgeries

	Surgical Procedure	Date
1.
2.
3.
4.
5.
6.

Ocular Surgeries - Check if you have received the following procedures and year performed.

	Check all that apply	Surgeon Name	Date
Cataract Surgery - Right Eye
Cataract Surgery - Left Eye
Retinal Surgery - Right Eye
Retinal Surgery - Left Eye
Other
Other

Pharmacy Information

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Fax Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Fax Number

Please enter a valid phone number.

Advanced Directives

What type of advanced directive do you have? *

None

Do Not Resuscitate

Durable

Power of Attorney

Living Will

HC Proxy

Do you take any medications? *

Yes

List all medications you take, prescription and non-prescription, and the dosage

	Medication Name	Dosage/Strength & Frequency
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Do you have any medication and/or food allergies? *

Yes

No known allergies

List all known allergies (drugs, food, animals, etc.)

	Allergic to	Reaction
1.
2.
3.
4.
5.
6.
7.
8.

Past or Present Medication Usage

Have you ever taken Plaquenil/Elmiron?

Elmiron (pentosan polysulfate) Usage *

Never

Present

Past- Year Start/Stopped

Plaquenil (hydroxychloroquine) Usage *

Never

Present

Past- Year Start/Stopped

Check if any family member(s) has had any of the following conditions.

	Mother	Father	Brother	Sister	Other	Details
Adopted/Unknown (Check OTHER column)
Anemia
Arthritis
Blindness
Cancer (State Type in Details column)
Cataract
Diabetes
Diabetic Retinopathy
Glaucoma
Heart Disease
Hepatitis
Hypertension
Kidney Disease
Macular Degeneration
Retinal Detachment
Stroke
Tuberculosis
Thyroid Disease
Uveitis

Marital Status

Married

Single

Widow/Widower

Divorced

Separated

Domestic Partnership

Do you smoke cigarettes/cigars? *

Yes

Do you drink alcohol? *

Yes

Past and present drug use (legal or illegal). It is important for drug and anesthetic interactions. Please indicate if we need to be aware of this: *

Yes

What is your occupation?

Are you still working? *

Yes

Have you had a blood transfusion since 1977? *

Yes

Living Conditions *

Alone

Nursing home

Caretaker/family

Other-please specify

Do you exercise? *

Yes

Do you have or have you ever had any pets? *

Yes

Review of Symptoms

Constitutional

Check all that apply

Jaw Pain

Fever

Weight Loss

Fatigue

Loss of Appetite

Trouble Sleeping

Other

Cardiovascular

Check all that apply

Chest Pain

Swelling of Feet

Endocrine

Check all that apply

Excessive Thirst

Excessive Urination

Cold Intolerance

Heat Intolerance

Other

Gastrointestinal

Check all that apply

Abdominal Pain

Nausea

Diarrhea

Constipation

Other

Respiratory

Check all that apply

Wheezing

Cough

Shortness of Breath

Other

Musculoskeletal

Check all that apply

Muscle Aches

Joint Pain

Difficulty Laying Flat from Muscular Discomfort

HENT

Check all that apply

Hearing Loss

Sore Throat

Runny Nose

Other

Neurologic

Check all that apply

Weakness

Headaches

Scalp Tenderness

Dizziness

Paralysis of Extremities

Tremor

Genitourinary

Check all that apply

Pain/Burning with Urination

Other

Integumentary

Check all that apply

Rash

Change in Mole

Hematology / Oncology

Check all that apply

Easy Bruising

Prolonged Bleeding

Clotting Problems

Other

Psychiatric

Check all that apply

Loss of Memory

Confusion

Grieving

	Yes	No	Date/Year
Flu
Pneumonia
COVID-19