Patient Registration Form Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Patient InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number*Please provide a telephone number, with area code, so we can contact you.Daytime PhoneCell PhoneEmail AddressPlease provide us your email address.Personal InformationGender* Female Male Date of Birth* MM slash DD slash YYYY Social Security Number (last 4 digits only!)Communication PreferenceEmailText MessageTelephoneEye HistoryPlease check off any current conditions you suffer from Headaches Glare/Light Sensitivity Tired Eyes Amblyopia (lazy eye) Burning Dryness Watery Eyes Eye Pain and/or Soreness Foreign Body Sensation Infection of Eye or Lid Itching Mucous Discharge Drooping eyelid(s) Redness Sandy or Gritty Feeling Strabismus (crossed eye) Blurred Vision at Distance Blurred Vision at Near Haloes Double Vision Floaters or Spots Fluctuating Vision Loss of Vision Loss of Side Vision Glasses HistoryDo you wear glasses?* Yes No Contact Lens HistoryDo you wear contact lenses?* Yes No Medical HistoryPlease list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)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 prescription and over-the-counter medications you take and for what conditionsPlease list all drug allergies you havePlease check off any current conditions you suffer from Chronic fever, unexpected weight loss/gain, fatigue Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat) Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet) Respiratory problems (eg. Shortness of breath, wheezing, coughing) Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting) Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems) Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints) Skin problems (eg. Rashes, excessive dryness, growths or lumps) Neurological problems (eg. Numbness, weakness, headaches, “blackouts”) Psychiatric problems (eg. Depression, anxiety) Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time) Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands) Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens) Primary InsuranceInsurance Company NameInsurance Company Phone NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insured's Name First Last Identification NumberGroup NumberInsured's Date of Birth MM slash DD slash YYYY Patient's Relation to InsuredSecondary InsuranceDo you have secondary insurance? Yes No Insurance Company NameInsurance Company Phone NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insured's Name First Last Identification NumberGroup NumberInsured's Date of Birth MM slash DD slash YYYY Relation to InsuredCommentsIf you have any comments you would like to add, please enter them here.Privacy PolicyHealth Information Protection* I have read and agree to the Privacy Policy PhoneThis field is for validation purposes and should be left unchanged. Δ
