COLUMBIADOCTORS OPHTHALMOLOGY

635 W. 165th Street, New York, NY 10032 880 3rd Avenue 2nd Floor, New York, NY 10022 15 W. 65th Street, New York, NY 10023 119 Prospect Avenue, Ridgewood, NJ 07450

PATIENT REGISTRATION INFORMATION

Date: ____________ MR#:______________ Date of Birth: _____________ Age: ______________

Last Name: __________________ First Name: ____________________ Middle Initial: ____ Gender: Male Female

Address: ___________________________________________Apt#:_____________ City: _________________________

State: ___________ Zip Code: __________ Home Phone: ____________________ Cell Phone: ____________________

Email: ___________________________________

Marital Status (circle one): Single/Married/Div./Sep./Widowed Spouse’s Name (if applicable): _____________________

Mother’s First Name: __________________________ Father’s First Name: _____________________________________

Employer: _____________________________________________ Occupation: _________________________________

Business Address: ________________________________________________ Business Phone: ___________________

Primary Care Physician: ______________________________________ Phone: _________________________________

Address: __________________________________________________________________________________________

Pharmacy Address: ______________________________________________ Phone: ____________________________

Referred by: ___________________________________

In case of emergency, who should we contact? __________________________________ Phone: ___________________

Workman’s Compensation: _______________________ No Fault: ___________________________

PRIMARY INSURANCE:

Person responsible for account: _______________________________ Phone: _________________________________

Relationship to Patient: _______________________ Date of Birth: _______________

Address (if different from patient): _____________________________________________________________________

Ins. Company: ___________________________Ins. Company Address: ______________________________________

Subscriber ID#: _____________________________ Group #: _________________________Co-pay: $______________

ADDITIONAL INSURANCE:

Person responsible for account: _______________________________ Phone: _________________________________

Relationship to Patient: _______________________ Date of Birth: _______________

Address (if different from patient): ______________________________________________________________________

Ins. Company: ___________________________Ins. Company Address: _______________________________________

Subscriber ID#: _____________________________ Group #: _________________________Co-pay: $______________

Signature of Responsible Party: ____________________________________ Date:_____________________

Columbia Ophthalmology Consultants Patient Medical History Questionnaire

PATIENTN~ .DOB: _

ALLERGIES: _

SENSITIVE TO: SOAPS? (1YES [1NO TAPES? [] YES (J NO OTHER _WOMEN, ARE YOU PREGNANT? [] YES [ ] NODO YOU EVER TAKE ASPIRIN, PLAVIX, COUMADIN, LOVENOX []YES [] NOEYE OR EYELID RELATED PROBLEMS: [] NO

[] Glaucoma [] Strabismus / crossed eyes [ ] Thyroid eye disease / Graves' disease[ ] Retinal detachment [ ] Macular degeneration [ ] Eye inflammation( J Droopy eyelids [ IAmblyopia / "lazy eye" [ ] Eye injury[ ] Double vision [ ] Tearing [ ] Other _[] Previous eye surgery? What kind(s) _[ ] Previous face, brow, eyelid, tear duct, or orbital surgery? What kind(s) _[] Previous cosmetic facial procedures? (Botox, fillers, peels, LASER, etc.) What kind(s)

[] Dry eye

SYSTEMIC PROBLEMS: [ ] NO[ J Fevers [ 1Night Sweats [] Fatigue

EAR, NOSE OR THROAT PROBLEMS: [] NO[ ] Hearing loss [] Chronic Allergies [] Sinusitis

[] Unexplained weight loss

[] Dry MouthCARDIOVASCULAR PROBLEMS: [] NO

[ ] High blood pressure [ ] Heart attack (MI)[] Angina (chest pain) [] Congestive heart failure[ ] Heart valve disease / murmur [ ] Pacemaker[ ] Blocked circulation to extremities or to carotid arteries

[ ] Coronary artery disease[] Irregular heart rhytlun / Atrial fibrillation(] Other

RESPIRATORY PROBLEMS: [] NO[ ] Asthma [ ] Emphysema[ ] Chronic cough [ ] Pneumonia[ ] Recent respiratory infection [ ] Shortness of breath

[ ] Chronic bronchitis[ ] Tuberculosis[ ] Home oxygen use

[] Other

GASTROINTESTINAL / ENDOCRINE PROBLEMS: [] NO[ ] Diabetes [ ] Thyroid disease [] Other

CLOTTING DISORDERS: [] NO[ ] Current anticoagulant therapy[ ] Bruise easy or frequent nose bleeds

[ ] Inflammatory Bowel Disease

[] Currently taking Coumadin, Aspirin, Lovenox[] Other

MUSCLE, JOINT, OR NERVE DISEASE: E] NO[ ] Arthritis [] Chronic back or neck pain[ ] Stroke [ ] Seizure disorders[ ] Dementia or Alzheimer's [ ] Fibromyalgia

[ ] Lupus / SLE[ ] Psychiatric illness[] Other

BLADDER/KIDNEY PROBLEMS: [] NO[] Frequent infections [] Incontinent of urine[] Other

HISTORY OF SLOW OR POOR WOUND HEALINGHISTORY OF COLD SORES. HERPES, SHINGLESHISTORY OF KELOIDSHISTORY OF SKIN CANCERHISTORY OF OTHER CANCER(S)

[] YES[] YES[] YES[] YES[] YES

[] Kidney Failure requiring dialysis

[]NO[] NO[]NO[]NO[]NO

TYPE: _TYPE:

HEPATITIS [] NO [] YES WHEN?POSITIVE HIV TEST: [ ] NO [] YES WHEN?

Type: BA C

PROBLEMS TOLERATING ANESTHESIA:TO LOCAL ANESTHETIC [] YES [ ] NO TO GENERAL ANESTHETIC [ ] YES [] NO

[] NO[ ] NO MACULAR DEGENERATION [] YESOTHER EYE CONDITIONS?

FAMILY HISTORY: GLAUCOMA [] YESTHYROID DISEASE [ ] YES [] NOSOCIAL HABITS:

SmokingAlcohol use

[ ] Never [] Past[ ] Never [ ] Rare or Social[ ] Recovering alcoholism

Drug use: [ ] Never [ ] Past

[] Current packs/ day[] Small Amount Daily[] Chronic Current Use[] Current

CURRENT MEDICATIONS (including Supplements and Herbals): _

Primary Care Physician: Telephone: _Address:Preferred Pharmacy: Telephone: _Remewedby: ~D

COLUMBIADOCTORS OPHTHALMOLOGY

Date: __________________________________________________________________________ Name: _________________________________________________________________________ Physician you are seeing today: _____________________________________________________ In addition to our medical ophthalmology services, our physicians also specialize in laser refractive surgery (LASIK, Wavefront, PRK) and numerous aesthetic and rejuvenation procedures around the eyes. To ensure we are meeting our patitns’ needs, we ask that you complete the following questionnaire. Please check all that apply. These are the areas of interest or concern to me:

Laser refractive surgery (LASIK, Wavefront, PRK) Droopy upper or lower eyelids Excess skin on the eyelids Droopy or angry appearing eyebrows Bags under the eyes Bumps or skin tags on the eyelids or face Wrinkles and fine lines Skin discoloration or hyperpigmentation Dark circles or puffiness around the eyes Desire for longer, fuller or darker eyelashes Botox Dermal fillers (Juvederm, Restylane, Radiesse) None of the above concerns me

Do we have your permission to send information via email/mail or call you regarding the above procedures and updates about our practice?

Yes No, please do not contact me Email address: ______________________________________________________ Telephone number: __________________________________________________ How did you hear about us (please specify): My physician: ________________________________ A friend or family member: ______________________ Internet: _____________________________________ Other: ______________________________________

Thank you! Patient Signature: ______________________________________

COLUMBIADOCTORS OPHTHALMOLOGY

CONSENT FOR MEDICAL PHOTOGRAPHS

Patient Name: ______________________________________ D.O.B.: ___________________________ I, ___________________________________________________________________, give my consent to ColumbiaDoctors Ophthalmology, or any person designated by Dr. Bryan Winn to photograph me during the course of my treatment(s) in order to demonstrate my condition or disorder, subsequent therapy, including surgical procedures when I may be sedated or anesthetized, and the results of such therapy. I understand that such photographs will be treated as confidential except as authorized by me in writing. I agree that such photographs become the sole property of ColumbiaDcotros Ophthalmology/Columbia University and that they may dispose of them at any time. (Please cross out any area in which you do not wish to participate). I further give my consent to ColumbiaDoctors Ophthalmology, or any person designated by Dr. Bryan Winn to use photographs of me for the following use:

________ Scientific papers, publications in medical journals, medical and paramedical personnel trainings, and membership requirements for medical societies and certification boards.

________

Promotional purposes (i.e. practice brochures, website, newsletters and external advertisements.) I understand that at no time will my personal information and/or name be used.

________

I waive all rights of publicity and release ColumbiaDoctors Ophthalmology and its employed or contract photographers from liability with respect to reputable uses of my said photographic image and verbal testimonials for promotional purposes.

________

I understand that this authorization is valid for all pictures taken during the course of my treatment(s). If at any time I wish to revoke this authorization I agree to notify ColumbiaDoctors Ophthalmology in writing of my wishes.

SIGNATURE: _______________________________________ DATE: _____________________ WITNESS: __________________________________________ DATE: _____________________

COLUMBIADOCTORS OPHTHALMOLOGY

AUTHORIZATION OF BENEFITS

Name of Beneficiary: ______________________________________________

Health Insurance Claim #: __________________________________________

I request that payment of authorized health insurance benefits, including Medicare and Medigap, be made

either to me or on my behalf to Dr.________________ for services furnished to me by this provider. I authorize

any holder of medical information about me to release to the Health Care Financing Administration and its

agents, any information needed to determine these benefits payable for related services.

Signature of Responsible Party: __________________________________ Date: _____________

Commercial Insurance

I hereby authorize direct payment of surgical/medical benefits to Dr._________________ for services rendered

by him/her in person or under his/her supervision. I understand that I am financially responsible for any balance

not covered by my insurance, including co-pays, deductibles, refractions, and differences between surgeon’s

charges and allowable. I hereby authorize Dr.______________________ to release any medical or incidental

information that may be necessary for either medical care or in processing applications for financial benefits.

Signature of Responsible Party: __________________________________ Date: _____________

Advance notice regarding Insurance Reimbursement and Beneficiary Agreement

I have been informed that refraction (the measurement of one’s eyeglass prescription and the determination of

the best visual sharpness) is usually not considered by insurance companies, health maintenance

organizations, and Medicare to be medically reasonable of necessary. Knowing this, I have instructed the

doctor to proceed with the services. If insurance decides to reduce or even deny the fee or services, I agree to

pay the doctor’s fee in full.

Signature of Responsible Party: _________________________________ Date: ______________

Revised October 2007

Health Insurance Portability and Accountability Act (HIPAA) HIPAA Compliance/Columbia University Medical Center 630 West 168th Street, Box 159 New York, NY 10032/ T(212) 342-0059 F(212)342-5173 http://www.cumc.columbia.edu/hipaa/

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT

DATE:___________________

I acknowledge that I was provided with a copy of the Columbia University Medical Center Notice of Privacy Practices.

_____________________________ ________________________________

Patient Name (Print) Patient Signature

If completed by a patient’s personal representative, please print and

sign your name in the space below

________________________________ _____________________________

Personal Representative (Print) Personal Representative’s Signature

_____________________________ Relationship

For Columbia University Medical Center use only

Complete this section if this form is not signed and dated by the patient or patient’s

personal representative.

I have made a good faith effort to obtain a written acknowledgement of receipt of

Columbia University Medical Center’s Notice of Privacy Practices but was unable to

for the following reason:

□ Patient refused to sign

□ Patient unable to sign □ Other __________________

_____________________________ _________________________

Employee Name Date

This form should be placed in the patient’s medical record