Regency Online Patient Forms

Patient Information

First Name

*This field is required

Last Name

*This field is required

Nickname

Birth Sex

Male Female

*This field is required

Address

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Apt/Suite #

City

*This field is required

State

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Zip Code

*This field is required

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

*This field is required

Occupation

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

Marital Status

Race

Ethnicity

Preferred Language

Misc/Guardian

Billing Information

Is The Billing Address Different?

Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

Apt/Suite:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Chief Complaint

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Reason for Visit

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Secondary Complaints

REVIEW OF OCULAR SYSTEM

Ocular History

Ocular Surgery

Last Eye Exam

Doctor

Computer Use

Do you:

Wear Glasses?

When do you wear them?

Wear Contacts?

Brand of Current Contacts

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Other Health Problems?

Medical History

Current Medications

No Medications

Drug Allergies

No Known Drug Allergies

Primary Care Physician

Primary care phone #

Notes

HbA1C

Taken

Please Describe any Injuries or Surgeries you have had

Family Medical History

Social History

Smoking Status

*This field is required

Alcohol Use

*This field is required

Illegal Drug Use

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Type

Pregnant

Nursing

Occupation

Hobbies

Office Policies Agreement

Please review the following agreement. Sign below to acknowledge and attach your signature to the final PDF.

Please ADD the above numbers together.