Forms


REGISTRATION FORM &
LIFESTYLE QUESTIONNAIRE
Secure Click here to go to the secure online form.
REGISTRATION FORM
MAIN INFORMATION
Account Number   
Social Security Number
Date of Birth    Age    Sex
Allergies
First Name    Initial
Last Name
Home Phone
Address
City    State  
Zip
Patient Employed By
Occupation   
Business Address
Business Phone
Spouse's Name
Spouse's Employer
Parent's Name (if minor)
Parent's Employer
Parent's Business Address
Emergency Contact
Phone Number
Referred by Doctor
Primary Doctor
PRIMARY INSURANCE
Person Responsible for Account
  
Relationship to Patient
Birth Date   
Social Security Number   
Phone
Address if Different From Patient   
Insurance Company
Insured Employer
Insurance Address
  
Contract Number
Subscriber   
ADDITIONAL INSURANCE
Person Responsible for Account   
Relationship to Patient
Birth Date   
Social Security Number   
Phone
Address if Different From Patient   
Insurance Company
Insured Employer
Insurance Address
  
Contract Number
Subscriber   
Release of Medical Information and Assignment of Benefits
I authorize the release of medical information necessary to treat my condition including diagnosis and records. I authorize payments to be made directly to Rochester Eye & Laser Center. I understand that I am financially responsible for those charges not paid by my insurance or any insurance payment made directly to me instead of the Rochester Eye & Laser Center. I am also aware that I will be charged a fee for any missed appointments without calling the doctors office to cancel in advance.
Medicare: I request that payment of authorized Medicare benefits be made either to me or on my behalf to my physicians, as listed, for any services. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information required to process my Medicare Claims.
Patient's Digital Signature

Date   
Guardian's Digital Signature (if minor)

Date   
LIFESTYLE QUESTIONNAIRE
Things you should know: Your doctor or a technician may do a refraction during your visit today. A refraction may be necessary to: prescribe glasses/contact lenses), to determine the best level of vision your eyes are capable of, to determine why you are not seeing at the level of 20/20, or to diagnose certain conditions such as cataracts or macular degeneration. Some insurance plans do not cover refractions. MEDICARE does not cover them. Blue Choice and Preferred Care may cover them under certain circumstances. If your Plan does not cover refractions, you will be asked to pay for this service upon checkout. If you have any questions, please feel free to ask our front staff, your doctor, or a technician.
THINGS WE WOULD LIKE TO KNOW ABOUT YOU

A) I am involved in the following activities:
Computers. How many hours per day?
Sing.  
Play an Instrument. List instrument(s)
Play Sports. List sport(s)
Gardening.  
Hobbies. List hobbies
Use Power Tools.  

B) Questions about glasses:
I wear my glasses all day.
I have questions about lighter weight frames and thinnger lenses.

C) Questions about Sunglasses:
I wear sunglasses.
I wear polarized lenses.
I have questions about prescription sunglasses.

D) Questions about Safety:
I have questions about clear vision and/or eye safety around the home or at work.

SUBMIT