Step 1 of 6 - Contact Information 0% HiddenPatient ID: We would like to welcome you to our practice and ask that you kindly complete all information listed. Please bring the information with you to your appointment so we may include it in your file.Office Location* Dover Seaford Millville Name* First Last Date of Birth* MM slash DD slash YYYY Age* Social Security Number Marital Status Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender:* Male Female Home Phone*Work Phone*Cell Phone*Email* Occupation Employer Employer Phone*Family Doctor / PCP Family Doctor / PCP Phone*Emergency Contact Emergency Contact Phone* Upon my request, I hereby authorize my medical records and/or personal information to be released to the following family members/doctor offices (this includes requests for medication refills, office notes, etc.): Recipients:Name of Recipient First Last Relationship Phone NumberName of Recipient First Last Relationship Phone Number DemographicPrimary Language* English French Spanish Ethnicity* Latino or Hispanic Not Latino or Hispanic Race* White Black or African American Native Hawaiian or Other Pacific Island American Indian or Alaska Native Asian Medical HistoryPlease choose YES or NO if you ever been diagnosed with any of the following:Cataracts* Yes No Glaucoma* Yes No Retinal Detachment* Yes No Macular Degeneration* Yes No Any other eye diseases or conditions:Have you ever had any injuries or surgeries to your eyes (including laser)?* Yes No If yes, please explain.Do you currently have any of the following problems? Please choose YES or NO. If Yes, please explain.Chronic fever, fatigue, unexpected weight gain/loss* Yes No If yes, please explain.Ear/nose/throat problems*(e.g. hearing loss, sinus infection, sore throat) Yes No If yes, please explain.Heart problems* Yes No (e.g. chest pain, irregular heartbeat, high blood pressure)If yes, please explain.Respiratory problems*(e.g. shortness of breath, wheezing, coughing, asthma) Yes No If yes, please explain.Gastrointestinal problems*(e.g. heartburn, abdominal pain, diarrhea, vomiting) Yes No If yes, please explain.Urinary problems*(e.g. pain or discomfort, blood in urine, difficulty voiding) Yes No If yes, please explain.Skin problems*(e.g. rashes, excessive dryness) Yes No If yes, please explain.Musculoskeletal problems*(e.g. muscle aches, joint pain, swollen joints) Yes No If yes, please explain.Neurological problems*(e.g. numbness, weakness, headache) Yes No If yes, please explain.Psychiatric problems*(e.g. depression, anxiety) Yes No If yes, please explain.Endocrine problems*(e.g. diabetes, thyroid disease) Yes No If yes, please explain.Blood problems*(e.g. anemia, bleeding tendency) Yes No If yes, please explain.Have you ever been exposed to Hepatitis B or Hepatitis C?* Yes No If yes, please explain.Have you ever tested positive for the HIV Virus?* Yes No If yes, please explain.Smoking:Do you or have you ever smoked?* Yes No If yes, how many pack per day? How long ago did you quit smoking? Primary Pharmacy (Where would you like your prescriptions sent to):Pharmacy Name Location PhoneSecondary PharmacyPharmacy Name Location PhonePlease list any ALLERGIES and REACTIONS:AllergyReaction Please list all medications, including over the counter and eye drops that you are currently taking:Medication NameAmount/Dosage Medical InsurancePlease make every effort to fill in the information on the pages requesting your insurance information. Incomplete information may prevent your visit from being billed to the appropriate insurance plan.Primary Medical Insurance:Company PhonePolicy # Group # Subscriber First Last Subscriber's Date of Birth MM slash DD slash YYYY Subscriber's Social Security Number Relationship to Patient Self Spouse Parent Subscriber's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Specialist Copay: Secondary Medical Insurance:Company PhonePolicy # Group # Subscriber First Last Subscriber's Date of Birth MM slash DD slash YYYY Subscriber's Social Security Number Relationship to Patient Self Spouse Parent Subscriber's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Specialist Copay: Tertiary Medical Insurance:Company PhonePolicy # Group # Subscriber First Last Subscriber's Date of Birth MM slash DD slash YYYY Subscriber's Social Security Number Relationship to Patient Self Spouse Parent Subscriber's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Specialist Copay: Is this visit the result of an accident? Yes No What type of accident? Auto Employment Date of Accident MM slash DD slash YYYY Insurance Information:CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
