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Patient Registration Form

Patient Information

Address
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 Preferencered to our office?
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 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
Street Address*
Address Line 2*
City*
State / Province / Region*
ZIP / Postal Code*
Country*
Insured's Name
Name*
Identification Number*
Group Number*
Insured's Date of Birth*
Patient's Relation to Insured*
Secondary Insurance
Do you have secondary insurance?
Comments
If you have any comments you would like to add, please enter them here.
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Contact Information

Office Hours

  • Monday 9:00 AM - 6:00 PM
  • Tuesday 9:00 AM - 6:00 PM
  • Wednesday 9:00 AM - 6:00 PM
  • Thursday 9:00 AM - 6:00 PM
  • Friday 9:00 AM - 6:00 PM
  • Saturday 10:00 AM - 2:00 PM
  • Sunday Closed
  • Monday 9:00am - 6:00pm
  • Tuesday 9:00am - 6:00pm
  • Wednesday 9:00am - 6:00pm
  • Thursday 9:00am - 6:00pm
  • Friday 9:00am - 6:00pm
  • Saturday 10:00am - 2:00pm
  • Sunday Closed
  • Monday 8:00am - 5:00pm
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

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