Patient Registration Form

Patient Registration Form

Please fill in the form below to set up an appointment.

Location

Doctor

Reason for Appointment

Preferred Date & Times*

Patient Type*

Please let us know if you are a new or existing patient.

First Name *

Last Name *

Phone

Email Address*

Best Time to be Reached for Confirmation*

Comments

Patient Information

Name*

Prefix

First Name

Last Name

Suffix

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Please provide a telephone number, with area code, so we can contact you

Daytime Phone

Cell Phone

Email Address*

Please provide us with your email address.

Personal Information

Gender*

Date of Birth*

Social Security Number (last 4 digits only!)

Preferred Language*

Race*

Ethnicity*

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference

Eye History

Please check off any current conditions you suffer from

Glasses History

Do you wear glasses?*

Contact Lens History

Do you wear 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

Please check off any current conditions you suffer from

Primary Insurance

Insurance Company Name

Insurance Company Phone Number

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Insured's Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Comments

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

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