Optometric Vision Center of Claremont

Dr. Anna M. Torres, O.D. • 1420 N. Claremont Blvd., Ste. 209-B, Claremont, CA 91711

New Patient Registration & Medical History Form

1. Patient Information

Patient name *
SSN
Address *
State *
Check appropriate box:
Work phone
Spouse or parent's name
Work Phone (Spouse/Parent)
Whom may we thank for referring you?
Phone (Emergency)
Date *
Gender *
Birthdate *
Home phone
City *
Zip *
Patient's or parent's employer
Business address
Employer (Spouse/Parent)
If patient is a student, name of school/college
Person to contact in case of emergency

RESPONSIBLE PARTY

Name of person responsible for this account
Address
Driver's License #
Financial institution
Is this person currently a patient in our office?
Relationship to patient
Home phone
Birthdate
Employer
Work phone

2. Insurance Information

Primary Insurance

Name of insured
Birthdate
Date employed
Work Phone
Insurance company
Union or local #
How much is your deductible?
Max. annual benefit?
Relationship to patient
Social Security Number
Name of employer
Address of employer, City, State, Zip
Group #
Insurance co. address, City, State, Zip
How much have you used?

Secondary Insurance (Optional)

Do you have any additional insurance?
Relationship to patient (Secondary)
Group # (Secondary)
Name of insured (Secondary)
Insurance company (Secondary)

3. Medical History Questionnaire

Primary Care Physician's Name:
List any medications you are taking (including oral contraceptives,...
If yes, please list: (Medication Allergies)
List all major injuries, surgeries and/or hospitalizations you have ha...
Dr.'s Phone:
Do you have any allergies to medications:
For Women: Are you pregnant and/or nursing?

Have you had any of the following eye conditions?

Do you currently, or have you ever had any problems in the following areas?

Do you drive?
Do you use tobacco products?
Do you drink alcohol?
Do you use illegal drugs?
If yes, do you have visual difficulty when driving?
If yes, type/amount/how long (Tobacco)
If yes, type/amount/how long (Alcohol)
If yes, type/amount/how long (Illegal Drugs)

4. Family History

Please note any family history: parents, grandparents, siblings, children, living or deceased

5. Authorizations & Signatures

INSURANCE SIGNATURE ON FILE: I certify that the information given by me is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance/Medicare benefits.

RELEASE OF EXAMINATION FINDINGS: I authorize Dr. Torres to send a report of my examination to my physician, referring doctor and/or referring Health Professional.

45-DAY INSURANCE CLAIMS POLICY: It is our policy to allow 45 days for your carrier to pay the claim. If the claim has not been paid, payment from you will be expected.

RECEIPT OF PATIENT CONFIDENTIALITY POLICY (HIPAA): I have received and agreed to Dr. Torres patient confidentiality policy.

Signature of patient (or parent if minor) *
Relationship to patient
Date *
Authorized individuals to discuss care