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

*This field is required

Apt/Suite #

City

*This field is required

State

*This field is required

Zip Code

*This field is required

Cell Phone

*This field is required

Home Phone

*This field is required

Birthday

*This field is required

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

Marital Status

Race

Decline to specify American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other Race Unknown

Misc/Guardian

AUTHORIZED USERS TO PATIENT'S RECORDS (EMERGENCY CONTACT):

Authorized User 1 Name

Relation to Patient

Authorized User 2 Name

Relation to Patient

How did you hear about our office?

*This field is required

INSURANCE INFORMATION

Vision Insurance

*This field is required

Secondary Vision Insurance or Other insurance

Please list your Medical insurance below (In case a referral is needed to specialist or an ocular emergency is found):

Medical Insurance (used for your Primary Care Physician)

*This field is required

Secondary Medical Insurance or Other insurance

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:

Reason for Visit

*This field is required

Other reason for visit

*Required for medical/problem visits

Pharmacy Name

*Required for medical/problem visits

Pharmacy Phone

*Required for medical/problem visits

I elect the Retinal Screening to check the health of my eyes. ($39)

*This field is required

Secondary Complaint Additional Details

Ocular History

Cataract GLC Mac Degen Lazy Eye Trauma Dry Eye

Ocular Surgery

Lasik PRK Cataract Sx Retinal Sx Eyelid Sx

Ocular History Additional Details

Ocular Surgery Additional Details

Wear Glasses?

*This field is required

Wear Contacts?

*This field is required

ENDORCRINE:

Type 2 Diabetes Type 1 Diabetes Thyroid dysfunction Hormonal dysfunction

CARDIOVASCULAR:

Hypertension High Cholesterol Heart Disease Stroke

ALLERGIC / IMMUNOLOGIC:

Environmental allergy Rheumatoid arthritis Lupus

EAR, NOSE, THROAT:

Hearing Problems Sinus problems Dry throat/mouth

BLOOD/LYMPH:

Sickle cell anemeia Anemia Leukemia

NEUROLOGICAL:

Multiple sclerosis Epilepsy/Seizures Headaches

GENITAL, KIDNEY, BLADDER:

Urinary tract infections Kidney concerns STD: Herpes STD: HIV STD: Chlamydia

GASTROINTESTINAL:

Crohns Disease Ulcerative Colitis

MUSCLES, BONES, JOINTS:

Arthritis Fibromyalgia Mascular Dystrophy

RESPIRATORY:

Asthma Emphysema Upper respiratory tract infection Bronchitis

SKIN:

Eczema Rosacea

CONSTITUTIONAL:

Weight loss Cancer Trauma

PSYCHIATRIC:

Depression Panic disorder Schizophrenia

Problems not listed / Other health problems

Are you currently taking any medications?

*This field is required

Any allergies to medications?

*This field is required

Primary Care Physician

Primary care phone #

Family Medical / Ocular History

Glaucoma Mac Degen Lazy eye Cornea dz Diabetes Retinal dz Hereditary dz Blindness

Family Medical / Ocular History Additional Details

Preferred Language

*This field is required

Smoking Status

*This field is required

Alcohol Use

*This field is required

Illegal Drug Use

*This field is required

Are you currently pregnant?

*This field is required when Birth Sex is Female

Are you currently nursing?

*This field is required when Birth Sex is Female

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.

Patient Information

Billing Information

Chief Complaint