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 InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Cell PhoneHome PhoneWork PhonePreferred PhoneCellHomeWorkPlease make this my primary phone numberEmail AddressPlease provide us your email address.Personal InformationGender*FemaleMaleDate of Birth* Social Security Number (last 4 digits only!)Please enter a value between 0000 and 9999.Preferred Language*EnglishSpanishFrenchJapaneseDecline to specifyEthnicity*Decline to specifyHispanic or LatinoNative Hawaiian or other Pacific IslanderNot Hispanic or LatinoOccupationHow were you referred to our office?Friend or FamilyOther DoctorInsurance CompanyYelpGoogle SearchOtherReferral Status - OtherPlease let us know how you were referred to our office.Eye HistoryPlease check off any current conditions you suffer from Headaches Glare/Light Sensitivity Tired Eyes Dryness Watery Eyes Eye Pain and/or Soreness Foreign Body Sensation Itching Redness Blurred Vision at Distance Blurred Vision at Near Haloes Double Vision Floaters or Spots Loss of Vision Loss of Side Vision 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 HistoryDo you wear contact lenses?*YesNoWhat 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 value between 0 and 24.What is your typical wearing schedule? In days per week:Please enter a value between 0 and 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 HistoryWhen, 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?NoYes, 1 per weekYes, 1 per dayYes, 2 or 3 per dayYes, 4 or more per dayDo you smoke?NoYes, 1/2 a pack per dayYes, 1 pack per dayYes, more than 1 pack per dayPlease 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 conditionsPlease list all drug allergies you haveVision PlanCommon vision plans include VSP, MES, and DavisPlease bring all insurance cards with you to your appointment.Vision Plan NameInsured's Name First Last Identification NumberGroup NumberInsured's Date of Birth Patient's Relation to InsuredMedical InsuranceThe 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 NameMedical Plan TypePPOPOSHMOInsurance Company Phone NumberInsured's Name First Last Identification NumberGroup NumberInsured's Date of Birth Patient's Relation to InsuredCommentsIf you have any comments you would like to add, please enter them here.Privacy PolicyHealth Information Protection* I have read and agree to the Privacy Policy CommentsThis field is for validation purposes and should be left unchanged.
