Patient Registration Form

Please complete the information below and submit the form online. 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 Information

Name*

Prefix First Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

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

Email Address

Please provide us your email address.

Personal Information

Gender*

Female
Male

Date of Birth*

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference

Upcoming Appointment Questions

What is the major purpose of your upcoming appointment?*

Select ALL that apply

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Eye History

This field is hidden when viewing the form

Please check off any current conditions you suffer from

I stopped wearing glasses because:

I stopped wearing contact lenses because:

Glasses History

Do you wear glasses?*

Yes
No

What glasses do you own?

Other glasses:

Please tell us what other kinds of glasses you own.

How many hours a day do you use a digital device (i.e. computer, smart phone, tablet, etc...)?*

Please enter a number from 0 to 24.

Please check off any current conditions you suffer from

I am having problems with my current glasses
There are times when I would rather not be wearing glasses
I have problems with glare
I have problems with night vision
I am allergic to nickel (e.g. frames of glasses)
I don’t have spare set of glasses
My spare glasses have an incorrect prescription
My sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Do you wear contact lenses?*

Yes
No

What brand of contact lenses do you wear?

How often do you replace or dispose your contact lenses?

Please check off all that apply to you

I am having problems with my current contact lenses
There are times when I would rather not be wearing contact lenses
I am interested in changing or enhancing my eye color
I am interested in a non-surgical method of vision correction
I am interested in refractive laser surgery
I don't have a spare set of contact lenses
My spare contact lenses have an incorrect prescription

Medical History

When, approximately, was your last eye exam?*

Where did you get your last eye exam?

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When, approximately, was your last physical exam?

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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 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 Vision Insurance

Do you have vision insurance?*

Yes
No

Please bring all insurance cards with you to your appointment.

Insurance Company Name*

Insured's Name*

First Last

Insured's Date of Birth*

Insured's Social Security Number (last 4 digits only!)

Identification Number

Group Number

Patient's Relation to Insured*

Primary Medical Insurance

Do you have medical insurance?*

Yes
No

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insured's Name

First Last

Insured's Date of Birth

Insured's Social Security Number (last 4 digits only!)

Identification Number

Group Number

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Yes
No

If you have secondary coverage, please fill in the details below.

Insurance Company Name

Insured's Name

First Last

Insured's Date of Birth

Insured's Social Security Number (last 4 digits only!)

Identification Number

Group Number

Patient's Relation to Insured

Comments

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

Privacy Policy

Health Information Protection*

I have read and agree to the Privacy Policy

Name

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