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

Cell Phone

Home Phone

Work Phone

Preferred Phone

Cell
Home
Work

Please make this my primary phone number

Email Address

Please provide us your email address.

Personal Information

Gender*

Female
Male

Date of Birth*

Social Security Number (last 4 digits only!)

Please enter a number from 0000 to 9999.

Preferred Language*

Ethnicity*

Occupation

How were you referred to our office?

Referral Status - Other

Please let us know how you were referred to our office.

Eye History

Please check off any current conditions you suffer from

I am having problems seeing in the distance with my glasses.
I am having problems working at a computer with my glasses.
I am having problems reading with my glasses.

Contact Lens History

Do you wear contact lenses?*

Yes
No

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:

Please enter a number from 0 to 24.

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

Please enter a number from 0 to 7.

Please check off all that apply to you

I am interested in a non-surgical method of vision correction
I am interested in laser surgery
My contact lenses become dry or uncomfortable as the day progresses
My eyes feel itchy after I remove my contact lenses

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

Vision Plan

Common vision plans include VSP, MES, and Davis

Please bring all insurance cards with you to your appointment.

Vision Plan Name

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Medical Insurance

The plan you use for medical visits such as strep throat, a borken arm, eye infections, etc. Common ones are Blue Cross, Blue Shield, and Aetna.

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

Insurance Company Name

Medical Plan Type

PPO
POS
HMO

Insurance Company Phone Number

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Comments

If you have any comments you would like to add, please enter them here.

Privacy Policy

Health Information Protection*

I have read and agree to the Privacy Policy

Name

This field is for validation purposes and should be left unchanged.

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