Child's Last Name ________________________ First Name _______________________ M.I. ____   
Birth date  _______________    Present Age _____________     Male ______  Female ______
Home Address ___________________________  City ___________________ State _____  Zip __________
Home Tel. # ( ____ ) __________  Cell Phone # ( _____ ) _________)  Soc. Sec. # ______ ____  ________

Father's Name __________________________                  Mother's Name __________________________
   Soc. Sec. #  ______ _____ ______________                      Soc. Sec. #  ________ _____ ____________
     Employer  __________________________                        Employer   __________________________
 Work phone  ( _____ ) __________________                     Work Phone  ( _____ ) ___________________

Person with child today:  Mother ____   Father ____  Bro./Sister _____  Guardian ____ Other ________
Is the patient adopted?  Yes _____     No ______        Child's pediatrician _________________________

Emergency contact person ______________________________   Telephone ( ____ ) _________________
Primary Insurance Co. __________________________________  ID # ______________________________
Subscriber's Name   ______________________________   Birth date _________________
Second Insurance Co. __________________________________  ID # ______________________________
Subscriber's Name _______________________________   Birth date _________________
Who referred you today? _________________________________
Reason for today's visit _____________________________________________________________________
Which eye?  Right _____  Left _____  Both _____   How long a problem? __________________________
Motor Vehicle Accident ?   Yes _____  No _____    Insurance ___________________  Claim # _________
Please circle all applicable:
    PREVIOUS EYE CARE                              FAMILY HISTORY                      
       Eye Glasses                                               Glaucoma                                   
       Contact lenses                                      Crossed/Turned Eye                        
      Prior eye surgery                                         "Lazy" eye                                
      Prior patching                                        Other _____________      

Child' medical history:     Asthma         ADD / ADHD          Cerebral Palsy         Developmental Delay  
                                       Diabetes         Down Syndrome        HIV / AIDS         Lyme Disease 
                               Other _________________________________________________________________      
                                                                                                                
Was child a premature baby?  No ___     Yes ___ (birth weight ) ____________  Weeks gestation ______
List all current medications _________________________________________________________________
List all eye drops currently used ____________________________________________________________
Drug allergies ____________________________________________________________________________
I request that payment of authorized benefits be made to Krosney, Berg, Talansky & Turtel, M.D.s, P.A.
for any services furnished to me by the provider.  I authorize any holder of medical information to
 release to my insurance company and its agents any information needed to determine these benefits
until I choose to revoke such authorization.

SIGNATURE ________________________________________   Date __________________