IDEZ01 Pediatric Registration Form

APPOINTMENT CHECKLIST-PEDIATRIC

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Current health insurance information, including ID card
Photo identification
Completed registration forms. They may be filled in online but must be printed.
The check-in time is when the patient presents completed registration forms, not when the patient arrives. Please arrive 20-30 minutes prior to your appointment time if forms need to be completed in the office.
Referral/Authorization (if required by your insurance)
List of all medications your child takes (including strengths/dosages)
Pharmacy information (name, address, and phone number)
Please bring a translator, if necessary.
Copays and other out of pocket expenses will be collected at check-in. We accept cash, check, and most credit cards.
Glasses and/or contact lenses (Please bring contact lens boxes with lens information.)
If relevant, please bring records pertaining to your child’s condition such as relevant MRI/CT results, labwork, operative reports, etc.
We require a parent or guardian accompany the child to the initial visit.
We ask that you not bring siblings or other family members that are not being seen to the appointment as they may distract your child during the examination.
Toys/activities for your child to play with as some appointments can take 2-3 hours.
Please allow sufficient travel time. If you arrive more than 20 minutes after your scheduled appointment time, you may be asked to reschedule.

Ideal EyeCare ● 6028 S. Fort Apache Road, Suite 101 ● Las Vegas, NV 89148

Ideal EyeCare Registration Form-Pediatric

Name *

First Name

Middle Name

Last Name

Date of BIrth *

Date

Age

Social Security Number *

Gender

Home Phone Number *

Please enter a valid phone number.

Cell Phone Number *

Please enter a valid phone number.

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Race *

Alaskan

American Indian

Asian

Black

Hawaiian/Pac Islander

Spanish/Latin

White

Other

Ethnicity

Preferred language

How did you hear about us?

Google/Internet Search

You Tube ad

Facebook/Instagram

Word of Mouth

Physician referral

Other

Pharmacy *

Pharmacy Phone Number

Please enter a valid phone number.

Pharmacy Cross Streets *

Referring Physician *

First Name

Last Name

Phone Number *

Please enter a valid phone number.

Primary Care Physician *

First Name

Last Name

Phone Number *

Please enter a valid phone number.

Emergency Contact *

First Name

Last Name

Phone Number *

Please enter a valid phone number.

Financial Responsibility for Dependent Patients: Parent/Guardian Information

Parent's Name *

First Name

Last Name

Check one *

Natural Parent

Stepparent

Foster Parent

Legal Guardian

Adoptive Parent

Other

Date of Birth *

Date

Age *

Home Phone Number *

Please enter a valid phone number.

Mobile Phone Number *

Please enter a valid phone number.

Work Phone Number *

Please enter a valid phone number.

Email *

example@example.com

Occupation *

Employer *

Social Security Number *

Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Please attach a photo of your government issued ID (driver’s license, passport or military ID, etc.). *

📎

Select Image of Government Issued ID

or drag and drop files here

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

Parent's Name *

First Name

Last Name

Check one *

Natural Parent

Stepparent

Foster Parent

Legal Guardian

Adoptive Parent

Other

Date of Birth *

Date

Age *

Home Phone Number *

Please enter a valid phone number.

Mobile Phone Number *

Please enter a valid phone number.

Work Phone Number *

Please enter a valid phone number.

Email *

example@example.com

Occupation *

Employer *

Insurance Information

Social Security Number *

Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Please attach a photo of your government issued ID (driver’s license, passport or military ID, etc.). *

📎

Select Image of Government Issued ID

or drag and drop files here

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

Primary Insurance

Insurance Name

ID #

Group #

Subscriber Name

Relationship to Patient

Subscriber Date of Birth

Please attach a photo of the FRONT side of your primary 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)

Please attach a photo of the BACK side of your primary 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)

Secondary Insurance

Insurance Name

ID #

Group #

Subscriber Name

Relationship to Patient

Subscriber Date of Birth

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)

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)

HIPAA Approved Contacts

	Name	Phone	Relationship	Date of Birth
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Patient’s or Authorized Person’s Signature
I understand that even if Ideal EyeCare is contracted with my insurance plan, I am ultimately responsible for payment of both covered and non-covered services performed during the course of my treatment. I understand that any payment collected today is an estimate of my total liability and additional monies may still be owed once my insurance plan has processed the claim. I request payment of
authorized benefits by my insurance plan be made to Ideal EyeCare for services rendered and request that Ideal EyeCare submit claims for payment for those services on my behalf to my insurance carrier. I authorize the release of any/all medical information to the insurance carrier or its agents to allow for benefit or claim determination. I understand that if Ideal EyeCare does not participate
with my insurance plan or if I have elected to receive care outside of my insurance coverage, I am assuming financial responsibility for all services rendered and no claim will be filed to my insurance company on my behalf. I certify that the information provided above is complete and accurate and assume any and all financial liability caused by omissions or inaccuracies.

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.

Signature of Patient/Legal Guardian *

We also offer a multitude of aesthetic services!

Whether your concerns are fine lines and wrinkles, facial volume loss, body contouring, brown spots or pigment, acne treatment/prevention, and/or tattoo removal, we have advanced solutions available for every skin type.

Yes, I would like more information.

No, thank you. I am not interested.

Medical History Questionanaire-Pediatric

Pediatrician

First Name

Last Name

Referring Doctor/Specialist

First Name

Last Name

What is the reason for your visit? *

Patient Height *

Patient Weight *

Does your child wear glasses? *

Yes

Does your child have a back up pair of eyewear? *

Yes

Does your child need a new pair of eyewear? *

Yes

Is your child interested in contact lenses? *

Yes

Does you child have any allergies?

Is your child CURRENTLY experiencing any of the following: Please mark all that apply and provide detail.

	Mark all that apply	Details
Abnormal Head Position
Blurry/Decreased Vision
Double Vision
Droopy Eyelid(s)
Dry Eyes
Eye Injury
Eye Pain/Burning
Eye Misalignment
Flashes/Floaters
Glare/Light Sensitivity
Growth/Bump in Lid
Headaches
Itchy Eyes/Eyelids
Red Eyes
Watery Eyes
Other
NONE (My child is not experiencing any of these symptoms)

Past Ocular History: Please mark all that apply and provide detail.

	Mark all that apply	Details
Amblyopia (Lazy Eye)
Aphakia
Astigmatism
Cataracts
Diabetic Retinopathy
Dry Eyes
Glaucoma
Hyperopia (Farsightedness)
Iritis/Uveitis
Keratoconus
Macular Degeneration (Dry)
Macular Degeneration (Wet)
Myopia (Nearsightedness)
Optic Neuritis
Retinal Detachment
Other
NONE (My child has never had any of these conditions)

Past Ocular Surgeries: Please mark all that apply and provide detail.

	Mark all that apply	Details
Blepharoplasty
Cataract Surgery
Corneal Transplant
Foreign Body Removal
LASIK/PRK/RK
Ptosis Repair
Punctal Plugs
Retinal Laser
RD Repair
Strabismus Surgery
Glaucoma Surgery
Vitrectomy
Other
NONE (My child has never had eye surgery)

Ocular Significant Illnesses/Conditions: Please mark all that apply and provide detail.

	Mark all that apply	Details
Bell’s Palsy
Brain Tumor
Cancer
Chicken Pox/Shingles
Diabetes-Type I
Diabetes-Type II
Diabetes-Diet Controlled
Diabetes-Insulin Use
Diabetes-Oral Medication(s) Use
Headaches/Migraines
Herpes Simplex
Histoplasmosis
HIV/AIDS
Hypertension
Meningitis
Myasthenia Gravis
Multiple Sclerosis
Marfan syndrome
JIA/JRA
Stroke/TIA
Syphilis
Thyroid disease
Other
NONE (My child has never had any of these conditions)

Other Past Medical Conditions/Illnesses. Please mark all that apply and provide detail.

	Check all that apply	Details
Anemia
Asthma
Autism
ADD/ADHD
Depression
Eczema
Hearing Loss
Cerebral Palsy
Kidney Disease
Lung Disease
MRSA
Developmental Delays
RSV
Psychiatric Disorder
Seizure Disorder
Irregular Heartbeat (Arrhythmia)
Other
Other
NONE (My child has never had any of these conditions)

Family History (Please mark all that apply and circle which family member)

	Parent	Sibling	Maternal Grandparent	Paternal Grandparent	Other
Blindness
Cataracts
Glaucoma
Strabismus
Amblyopia (Lazy Eye)
Macular Degeneration
Diabetes
Cancer
Heart Disease
Hypertension

Systemic Medications: Please list all OTC/supplements/Prescription Medications you take including dosage/strength. If your child does not take medications (OTC or RX)/vitamins/supplements), please type NONE. *

Ocular Medications: Please list all OTC/supplements/Rx medications, including dosage/strength. If your child does not take ocular medications, please type NONE. *

General Surgeries/Operations: Please include dates performed. If your child has never had any type of surgery or procedure, type NONE. *

Social History

Does anyone in the household use tobacco (cigarettes, vape, etc.). *

Yes

Drug use by mother during pregnancy? *

Yes

Not applicable

If yes, substance used:

Child resides with: *

Both parents

Mother

Father

Grandparent(s)

Foster parent

Other

Child attends: *

School

Daycare

Homeschool

Birth History

Gestational Age (in weeks) *

Weight (lbs and oz) *

Delivery type *

Vaginal

Cesarean section

Oxygen administered neonatally? *

Yes

If yes, duration:

If yes, delivered via

Nasal cannula

Mask

Delivery details *

Forceps used

Suction used

Not applicable

Nuchal cord #

Other deliver details not listed:

Review of Systems

Please review the separate list of conditions, signs, and symptoms and check any that apply to your child here. Provide details if necessary.

	Check any/all that apply	Details
Ear, Nose, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Integumentary (Skin)
Cancer
Musculoskeletal
Neurological
Hematologic/Lymphatic (Blood)
Endocrine
Allergic/Immunologic
Genetic Disorders
Infectious Disease
NONE. My child does not have any of the conditions or symptoms on the list provided to me.

I have completed this form as accurately as possible. I understand that providing incorrect information or omitting information can be dangerous to my child's health and it is my responsibility to inform the office of any changes in his/her/their health status.

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.

Signature *

FINANCIAL POLICY

The following information is regarding your account at Ideal EyeCare. Please read these policies carefully and discuss any questions or concerns with our staff. We look forward to providing you and your family with excellent eye care.

Payment is due at the time services are rendered. This may include co-pays, deductibles, co-insurance, non-covered services, etc. We accept all major credit cards as well as debit cards, cash, and checks.
It is your responsibility to know your insurance coverage and to provide our office with the most current and accurate information. While our staff is extremely knowledgeable about many insurance plans, coverages change frequently and we cannot be held liable for misquoted benefits or eligibility.
If your insurance requires a referral, you are responsible for contacting your primary care physician/pediatrician to obtain said referral. It is also your responsibility to verify that a valid referral is on file for all visits.
The determination of your best corrected vision is called a refraction. This is considered a non-covered service/procedure by most insurance companies. You will be responsible for the $60.00 fee when this service is
performed. Strabismus patients are responsible for an additional fee of $40.00 for a prism refraction (total $95.00). We will bill this service to your insurance as a courtesy, and if they pay any portion, you will be refunded their payment amount.
For those patients being followed for strabismus, a sensorimotor examination will be performed at each visit. This service is separate from the office visit and may be considered a diagnostic test by your insurance, resulting in
additional out-of- pocket cost to you.
Telemedicine visits, whether scheduled or requested, will be billed to your insurance company and you may be responsible for out-of-pocket costs such as copays or deductibles.
We do not participate with any vision plans and you are responsible for all “routine” and/or non-covered services provided to you or your child. This includes myopia management evaluations.
All “self pay” patients are required to pay in full at the time services are rendered. We offer a 20% prompt-pay discount on all professional services and will provide you with an itemized receipt.
Our office does not accept insurance liens, workers compensation, or attorney liens. Payment is the patient’s responsibility and is due in full at the time of service.
The parent bringing the child for treatment is responsible for payment, regardless of the terms of any divorce decree or custody arrangement.
All outstanding balances must be paid in full before scheduling surgery, except in emergent cases.
All delinquent accounts may be sent to a collection agency and you may be charged any/all applicable collection and attorney fees. Once an account has been transferred to collections, you and your immediate family members will be discharged from the practice.
All returned checks are subject to a $35.00 processing fee and will result in refusal to accept future payments by check.
Any account credit balance less than $2.00 will not be issued a refund check.
We charge a $25.00 per page fee for any and all forms that require the doctor’s signature and review. This service will not be billed to your insurance company. Payment is due before the form(s) will be released. A receipt will be provided at the time of payment.
There is a $50.00 per page fee for summary of care letters or other requests requiring a drafted and signed letter from the doctor.
You will be assessed a $50.00 NO SHOW fee for any appointment that is missed or cancelled within 24 hours of your scheduled appointment. You must pay this amount before you will be allowed to schedule another appointment. We offer reminder notifications be text/phone/email as a courtesy, but it is your responsibility to update your calendar. It is very important that you keep our office updated with your most current information.
Per NRS 629.021, we charge $0.60 per page for copies of your medical record, whether provided via paper or electronic access. You may also be assessed applicable postage costs if you prefer to have the records sent via mail. These fees are waived if records are transferred directly to another physician for continued care.

I have read and understand the above information.

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.

Signature of Patient/Legal Guardian *

	Allergy	Reaction	Severity-Mild	Severity-Moderate	Severity-Severe
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