Online Patient Registration Form

Patient Information

Prefix *
First *
Last *
Suffix *
Address *
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
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?
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 hospital surgeries you have ever had:
Please list all drug allergies you have
Please check off any current conditions you suffer from
Please bring all insurance cards with you to your appointment.

Primary Insurance

Insurance Company Name
Insurance Company Phone Number
Address
Insured's Name
Identification Number
Group Number
Insured's Date of Birth
Patient's Relation to Insured

Secondary Insurance

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