patient registration form

Select Location*

Gender*

Please check off any current conditions you suffer from

Do you wear glasses?*

Do you wear glasses?*

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 current conditions you suffer from​​​​​​​

Insurance Company Name

Insurance Company Phone Number

Insured's Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Do you have secondary insurance?

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