New Patient Paperwork

Because of security concerns, we do not allow for online submission of your new patient paperwork.  Please download (click on the down arrow below), print the form "RC New Patient Paperwork" below and fill out the information.  If you can bring that information to our office it will expedite your visit with us.  If you would like, you may also fax this information to us at 

(817) 336-8619 (fax)

Retina Consultants, PA 

Patient Information 

Date: ______________________ Patient #: _______________________  

Patient Name: _______________________________DOB: _________Marital Status: S M D W 

Social Security #: ___________________________________ Gender: Male Female 

Ethnicity: Caucasian Black/African American Hispanic/Latino Asian Other___________ 

Address:________________________________________City:___________State: _____Zip:_____ Home:_______________________Cell:______________________Email:______________________ 

Employer Name: __________________________________ Occupation: ______________________ 

Employment Status: Full-Time Part-Time Retired Unemployment Student 

Emergency Contact Information Name:______________________________Phone:____________________Relationship:_________ 

Other Doctor Information Referring Doctor:_________________________________________Phone:____________________ 

Primary Care Doctor:______________________________________Phone:____________________ Specialist:_______________________________________________Phone:_____________________ Specialist:_______________________________________________Phone:_____________________ 

Medical Record Release 

By signing this form, I authorize Retina Consultants, PA to release confidential health information about me to the friends/family listed below: Name:_____________________________Phone:___________________Relationship:___________ Name:_____________________________Phone:___________________Relationship:___________ Name:_____________________________Phone:__________________Relationship:____________ 

ASSIGNMENT OF BENEFITS/RELEASE OF INFORMATION OF PRIVACY PRACTICES Retina Consultants, PA (RC), and its physicians are committed to securing the privacy of your health information. Accordingly, we have provided you with a copy of our Notice of Privacy Practices. You are not required to read this notice. However, we would like your acknowledgment that you have been advised that RC has such a Notice of Privacy Practices. I hereby assign, transfer and set over to RC, all my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits; including medical, surgical psychiatric and/or substance abuse (drug or alcohol) information. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that this order does not relieve me of my obligation of pay such bills if not paid by my insurance company, or any balance due after payments by my insurance company.

 __________________________________________________________________________________________ 

Patient Signature Date 

Witness Date 

Primary Insurance Information 

Insurance Company:_________________________________Policy#:________________________________ Group#:___________________________

Policy Holder Name:______________________________________ Policy Holder SS #:_____________________________ Policy Holder DOB:___________________________ Patient Relationship: Self Spouse Child Secondary Insurance Information Insurance 

Company:_________________________________Policy#:________________________________ Group#:___________________________

Policy Holder Name:______________________________________ Policy Holder SS #:_____________________________ Policy Holder DOB:___________________________ Patient Relationship: Self Spouse Child 

PRIVACY POLICIES & PRACTICES I have received and read the privacy and practices notice given to me by Retina Consultants, PA. I understand that if I have any questions concerning the notice I am to contact the phone number below. Retina Consultants, PA : (817) 332-1782

 _____________________________________________ _______________ 

Patient Name (Print) Date 

_______________________________________________________________________ 

Patient Signature 

Allergies: [ ]Yes [ ]No If yes, ____________________________________________ 

Eye Drops/ Medications (Include instructions and which eye) 

___________________________________ 

______________________________ 

___________________________________ 

______________________________ 

___________________________________ 

______________________________ 

Medications: _______________________ _______________________ ____________________ ____________________ _______________________ _______________________ ____________________ ____________________ _______________________ _______________________ ____________________ ____________________ _______________________ _______________________ ____________________ ____________________ List Any Eye History/Surgery: (such as glaucoma, macular degeneration, etc.) _________________________________________________Date:_________________ _________________________________________________Date:_________________ Have you had cataract surgery: [ ] Yes [ ] No If so, which eye? _________________ Date: ______________ List Any Other Surgeries: _________________________________________________________________________ ______________________________________________________________________________________________ 

Medical Condition: 

Diabetes ____Year Diagnosed:_________ [ ] Insulin [ ] Non-Insulin 

Thyroid Disease ____Year Diagnosed:_________ 

Stroke: ____Year Diagnosed:___________ 

High Blood Pressure ____Year Diagnosed:_________ 

Heart Attack ____Year Diagnosed:_________ 

Kidney Failure: ____Year Diagnosed:___________ 

Heart Bypass ____Year Diagnosed:_________ 

Anemia: ____Year Diagnosed:___________ 

Congestive Heart Failure ____Year Diagnosed:_________ 

Cancer: ____Year Diagnosed:___________ 

Emphysema ____Year Diagnosed:_________ 

AIDS/HIV: ____Year Diagnosed:___________ 

Hepatitis Type: _____ ____Year Diagnosed:_________ 

Mental Illness: ____Year Diagnosed:___________ 

Illegal Drug Use?[ ]Currently [ ]Formerly _________________________________ 

Drink Alcohol?[ ]Yes [ ]No If yes, how much?__________ how often?__________ 

Do you smoke? [ ] Yes [ ]Formerly [ ] Never If yes, how much?__________ how often?__________ 

Family Health History Please check mark next to condition of family member (this excludes you or your spouse): 

Condition 

Family Member Condition Family Member (eg Mother, Father, Sister, Brother, Son, Daughter, Grandparent)

Diabetes ______ ________________ 

Stroke ______ ________________ 

Heart Attack ______ ________________ 

Macular Degeneration ______ ________________ 

Glaucoma ______ ________________ 

Retinal Detachment ______ ________________ 

Blindness ______ ________________ 

Other ______ ________________ 

Retina Consultants, PA 

909 9th Avenue 

Suite 404 

Fort Worth, TX 76104 

(817)332-1782

fax (817) 336-8619 

Dear Patient, It is policy of this office for the patients to pay for services at the time they are rendered. We accept Visa, MasterCard, Discover, American Express, personal checks, and cash payments. There is a fee on all returned checks. For those patients with Medicare, we will accept assignment on all claims. We will file all Medicare as well as secondary insurance claims; therefore, it is very important that we obtain all of your insurance information. If you do not have secondary coverage, you will be expected to pay 20% of the allowed charges at this time of check-out as well as any deductible. Also, any secondary co-insurance will be due at the time of check-out. PPO, POS, EPO patients will be expected to pay their co-payments for each visit or charges according to their individual plans. If your insurance plan requires a referral you must obtain one from your primary care doctor prior to your scheduled appointment. We also appreciate notification of any changes in your insurance coverage, name, address, and/or telephone number. We do accept work-in appointments according to patient symptoms. We ask that in the event you are unable to keep your scheduled appoitnment, you please give us at least 24 hours notice. “NO SHOWS” (appointments that are not kept and no notice is given) are not only inconsiderate to our physicians and our staff, they are also an unnecessary expense, in that this time could have been given to another patient. “NO SHOWS” you may be charged a $30 fee and/or face termination of the physician/patient relationship. Due to increasing overhead costs, we reserve the right to charge a fee per document request. These documents include, but are not limited to, letters written by our office, forms filled out by our physicians/staff, and/or copies of medical records, etc. These policies help our office to keep charges and expenses as low as possible. Your signature is requested below to verify acknowledgment of this policy. 

_________________________________________________ ________________ 

Patient Signature Date