Patient Registration Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name

Prefix

First

Last

Suffix

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Please provide a telephone number, with area code, so we can contact you.

Daytime Phone

Cell Phone

Email Address

Please provide us your email address.

Personal Information

Gender

Female Male

Date of Birth

Social Security Number (last 4 digits only!)

Preferred Language

Race

Ethnicity

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference

Eye History

Please check off any current conditions you suffer from

I stopped wearing glassesI stopped wearing contact lensesHeadachesGlare/Light SensitivityTired EyesAmblyopia (lazy eye)BurningDrynessWatery EyesEye Pain and/or SorenessForeign Body SensationInfection of Eye or LidItchingMucous DischargeDrooping eyelid(s)RednessSandy or Gritty FeelingStrabismus (crossed eye)Blurred Vision at DistanceBlurred Vision at NearHaloesDouble VisionFloaters or SpotsFluctuating VisionLoss of VisionLoss of Side Vision

Glasses History

Do you wear glasses?

YesNo

What glasses do you own?

Single VisionBifocalsSafety GlassesBackup GlassesProgressiveTrifocalsSports GlassesSunglassesOther

How many hours a day do you use a computer?

How many inches away, approximately, do you sit from your computer monitor?

Please check off any current conditions you suffer from

I am having problems with my current glassesThere are times when I would rather not be wearing glassesI have problems with glareI have problems with night visionI am allergic to nickel (e.g. frames of glasses)I don't have spare set of glassesMy spare glasses have an incorrect prescriptionMy sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Do you wear contact lenses?

YesNo

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

What is your typical wearing schedule? In days per week:

Please check off all that apply to yo

I am having problems with my current contact lensesThere are times when I would rather not be wearing contact lensesI am interested in changing or enhancing my eye colorI am interested in a non-surgical method of vision correctionI am interested in refractive laser surgeryI don't have a spare set of contact lensesMy spare contact lenses have an incorrect prescription

Medical History

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol?

Do you smoke?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list all hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all drug allergies you have

Please check off any current conditions you suffer from

Chronic fever, unexpected weight loss/gain, fatigueEar/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)Respiratory problems (eg. Shortness of breath, wheezing, coughing)Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)Skin problems (eg. Rashes, excessive dryness, growths or lumps)Neurological problems (eg. Numbness, weakness, headaches, "blackouts")Psychiatric problems (eg. Depression, anxiety)Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insurance Company Phone Number

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Insured's Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

YesNo

If you have coverage through another plan/organization, please fill in the details below.

Insurance Company Name

Insurance Company Phone Number

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Insured's Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Comments

Privacy Policy

Health Information Protection

I have read and agree to the Privacy policy

Thank you. We'll connect with you shortly to confirm your appointment.

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