Patient Registration Form

Demographics

Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Insurances

Medical Insurance Information
Medical Insurance Name:
Insurance ID:
Insurance Policy Group:
Insurance Phone Number:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:



Vision Insurance Information
Vision Insurance Name:
Insurance ID:
Insurance Policy Group:
Insurance Phone Number:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Medical History

General Profile
Whom may we thank for your referral?
Who is your Primary Care Physician:
Please list any Hobbies:
What do you normally wear for vision correction?
Are you interested in Laser Vision Correction?
Are you interested in Contact Lenses?
Have you ever worn Contact Lenses?
Do you have a back up pair of glasses for your contacts?
Do you Smoke?
If Yes, how many packs a day and for how long?
Are you taking any illegal drugs?
If Yes, how many packs a day and for how long?
Do you drink Alcohol?
If Yes,what type and for how long?
If applicable, are you Pregnant or Nursing?


Ocular History
When was your last eye exam?
Please list any Eye History such as: Sting, Burn, Itch, Surgery, Injury, Cataracts, Lazy Eye, Floaters, Flashes of Light, Glaucoma, Eye Turn, Retinal Problems, etc.
Please list any Eye medication that you currently take:


Medical History
Please list any Medical History such as: Diabetes, High Blood Pressure, Heart Problems, Thyroid Condition, HIV, Cancer, Headaches, etc.
Please list any Prescribed or Over The Counter medications that you are currently taking:
Do you have any Medication or Seasonal Allergies? Please list below:


Family History
Please list any Family Eye History such as: Cataracts, Lazy Eye, Floaters, Glaucoma, Eye Turn, Retinal Problems, etc.
Please list any Family Medical History such as: Diabetes, High Blood Pressure, Heart Problems, Thyroid Condition, HIV, Cancer, Headaches, etc.


Dilation of the the Eyes

In order for the doctor to thoroughly examine the inside of the eye for problems such as glaucoma, diabetes, cataracts, retinal holes/tears, detachments, high blood pressure, and some types of tumors, we need to put drops in the eyes to enlarge the pupils. Side effects of the dilation drops include increased sensitivity to bright light that last 4-6 hours and slightly blurred vision (mostly trouble focusing up close) for 2-3 hours. A free pair of disposable sunglasses will be provided for your convenience. We strongly recommend this procedure to all of our patients. There is no extra fee for this service. Please indicate your preference below:

Submit Information

Thank you for taking the time to fill out our online Patient Registration Form. You may click on the tabs above to review the information you have provided. Click on the button below to submit your information. If you have any questions please call our office for further assistance at (281) 373-1163.