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Patient Registration Form

Information

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

Select a Practitioner

Location

Patient Information

Prefix

Full Legal Name

Suffix

Address 1

Address 2

City

State

Zip Code

Home Phone

Daytime Phone

Mobile Phone

Fax Number

Email Address

Personal Information

Gender

Date of Birth

Marital Status

Employment

Employer

Occupation

Referer

Referer if Other

Eye History

I wear:

GlassesContact Lenses

Reason for Visit

Glasses History
(Skip if you don't wear glasses)

If Other Please Describe

How many hours a day do you use a computer?

How many inches away, approximately, do you sit from your computer monitor?

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 (Skip if you don't wear contacts)

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

How many hours per day?

How many days per week?

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?

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