Patient Registration Form

Patient Registration and Medical History Form

Please be sure to bring your medical insurance card, any eyewear, contact lenses, and contact solution.
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First Name
Middle Initial
Last Name
How did you hear about us?
Other
Birth Date
Last 4 of SSN
Sex
Employer/Occupation
Physical Address
City
State
Zip Code
Mailing Address
Email Address
Home Phone
Work Phone
Cell Phone
Communication Preference
Marital Status
Spouse Name
Spouse Phone
Spouse Employer
Primary Language
Race
Ethnicity
Medical Doctor
City
Pharmacy
City
If the patient is a child or student, list both parents
Mother
Phone Number
Employer
Father
Phone Number
Employer
If not the patient, who is responsible for the bill?
Relationship
Phone

Insurance Information

*We must have a copy of all insurance cards on the day of service*

Medicare
Medicaid
Medicare Supplement Insurance Name
Policy Number
Health Insurance Name
Policy Number
Policyholder Name
Policyholder Date of Birth
Vision Insurance Name
Policy Number
Policy Holder Name
Policyholder Date of Birth

Social History

Tobacco Products
Alcohol Use

Current Vision Correction

Do you currently wear glasses?
How often do you wear your glasses?
How often do you replace your contacts?

Review of Systems

Allergies
Medications / Supplements
Eye Surgery
Do you currently, or have you ever had any problems in the following areas?

Family Health History

Select all that apply.

Glaucoma
Other Family Members
Cataract
Other Family Members
Macular Degeneration
Other Family Members
Retinal Tears or Detachment
Other Family Members
Blindness AND/OR vision impairment
Other Family Members
Strabismus (eye turn)
Other Family Members
Amblyopia (lazy eye)
Other Family Members
Diabetes
Other Family Members
Cancer
Other Family Members
Heart Disease
Other Family Members
High Blood Pressure
Other Family Members
High Cholesterol
Other Family Members
Kidney Disease
Other Family Members
Stroke
Other Family Members
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