New Patient Registration Form

Thank you for choosing Fairway Eye Center. We feel privileged to be able to provide your eye care needs. Our highly trained staff is always ready to answer any questions you may have. We sincerely hope that your visit to our practice will be enjoyable.

For you first appointment at Fairway Eye Center, we require that you fill out a form with your information and medical history. To save time in the waiting room, fill out this form online before your appointment.

CONFIDENTIAL Patient Information: Please enter the data in the fields provided. Press the "Tab" key to forward to the next field. * First Name: * Last Name: Preferred Name: Status: Married    Widowed    Single    Minor    Separated    Divorced    Partnered for Years * Birth Date: / / * Age: * Social Security # - - * Street Address: * City: * State: * Zip: * Home Phone: ( ) - Cell Phone: ( ) - Work phone: ( ) - * Email Address: * How do you prefer to be contacted? Text     Email     Phone call only    Both Text/Email and Phone * Which Fairway Eye Center is your appointment located?     Fairway, KS      Liberty, MO * Patient Employer / School: * Occupation: Employer / School Address: City: State: Zip: Spouse or parent's name: Employer: Work Phone: ( ) - * How did you hear about our office? Relative or friend - Who?          Physician - Who? Yellow Pages Radio Newspaper Community Event * Person to contact in case of emergency: * Phone: ( ) - Responsible Party: Name of Responsible Party (if minor): Relationship to Patient: Phone (if different): ( ) - Address: City: State: Zip: Name fo Employer: Work phone: ( ) - Employer Address: City: State: Zip: Insurance: * Member Name: Relationship to Patient: Date of Birth: / / Social Security #: - - Name of Employer (if different from above) : Work phone: ( ) - Address: City: State: Zip: * Vision Insurance Carrier: Policy #: * Medical Insurance Carrier: Policy #: Examination Information: * Date of last Exam: / / * Name and/or location of previous Eye Doctor: * Do you currently wear glasses? Select Yes No How old are they? Complete the next 4 lines only if you wear contact lenses What kind of contacts do you wear? When and by who were you fit? What is your cleaning solution? Do you have a back up pair of glasses? Select Yes No Are the glasses prescription up to date? Select Yes No Do you replace your contacts as recommended? Select Yes No Do your eyes become dry with contacts? Select Yes No Family History: Please only personal or family history for the following conditions: Disease/Condition Self Family Member Disease/Condition Self Family Member Blindness Diabetes Cataracts Heart Disease Crossed Eyes High Blood Pressure Glaucoma Kidney Disease Macular Degeneration Lupus Retinal Detachment Thyroid Disease Arthritis Multiple Sclerosis Cancer Other Type of Cancer:         Social History: This information is kept strictly confidential. However you may discuss this portion directly with the doctor if you prefer. Do you use Tobacco Products? Select Yes No If yes: Type / amounts / period: Do you drink alcohol? Select Yes No If yes: Type / amounts / period: Do you drive? Select Yes No If yes: do you have a visual difficulty? Medical History: Do you have any allergies to medications? If yes, explain List any medication you take (including birth control, aspirin, over the counter medications and home remedies) Review of System Do you currently, or have you had any problems in the following areas: Fever Constipation Psychaitric: Weight Loss/ Gain Diarrhea Thyroid Allergies/ Hay Fever Genitals/ Kidney/ Bladder Diabetes Sinus Congestion Rheumatoid Arthritis Anemia Dry Throat/ Mouth Joint Pain Bleeding Heart Pain Muscle Pain Allergic: High Blood Pressure Headache   Stroke Migraines     Asthma Seizures   Chronic Bronchitis   Emphysema       Other Comments that you would like to add about your history: Eye and Visual Health Information Do you ever experience any of the following (check all that apply) Burning Uncomfortable Glasses Itchiness Sudden loss of vision Mucous Discharge Sensitivity to light Watery Eyes Fainting or dizziness Double Vision Blurry distance vision Flashes of Light Blurry near vision Glare or Halos Gritty feeling in vision Soreness Objects floating in vision Eye Strain Trouble seeing at night Headaches Dryness Redness   Other Visual Needs Do you….. Work on a computer for long periods of time? Have only one pair of glasses? Want information on thinner, lighter lenses? Wear bifocals? Want information on "no line" bifocals? Prefer not to wear glasses at times? Spend a lot of time outdoors? Ever find a need to wear prescription sunglasses? Have problems with glare of reflections (ie: night driving) Do you require safety glasses? Want more information about corrective vision surgery? Wear or have tried wearing contacts? What kind? Certification and Assignment To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my child, ever have a change in health. I certify that I, and/ or my dependent(s), have insurance coverage with * and assign directly to Dr. * Select Mark Bunde Tim Hug Rebecca O'Brien all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize that use of my signature on all insurance submissions. The above named Insurance Company payable for services. This content will end when my current treatment plan is complete or one year from the date of signed below.       * I acknowledge that I have received the Notice of Privacy Practices: * * / / (Type) Signature of Patient, Parent, Guardian or Personal Representative Today's Date