patient registration form

Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Select Location*

Name*

Address*


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?

Referral Status - Other

Communication Preference

Eye History


    Glasses History

    Do you wear glasses?*

      Contact Lens History

      Do you wear glasses?*

        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 eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

                          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 check off any current conditions you suffer from​​​​​​​

                                  Primary Insurance

                                  Please bring all insurance cards with you to your appointment.

                                  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

                                                Do you have secondary insurance?

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