Patient Registration Form

Online Patient Registration Form

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Please complete the information below and submit the form online, or if you prefer to 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.

Prefix*

First Name*

Last Name*

Suffix

Street Address*

Address Line 2

City*

State / Province / Region*

Zip / Postal Code*

Country*

Phone Number*

Daytime Phone

Cell Phone

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 conditions your suffer from

Primary Insurance

Please bring all insurance cards with you to your appointment

Insurance Company Name

Insurance Company Phone Number

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Insured's Name

Insured's First Name

Insured's Last Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Comments

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