online forms

In order to save you time when you come in for your appointment, we request that all new patients and patients who have not been seen in more than 3 years fill out and submit the New Patient Registration Form. There are two additional forms at the bottom of this page for you to print, fill out and bring with you to your appointment.

NEW PATIENT REGISTRATION FORM

Date

Name

Date of Birth

Gender

Marital Status

SSN

Birth State

Sports/Hobbies

Mother's Maiden Name (for children under 18 years old)

Race

Ethnicity

Height

Weight

Preferred Language

Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Extension

Employer/School

Occupation/School Grade

Email Address

Preferred Contact

Emergency Contact

Relation

Phone Number

Mother's Name

SSN

Address if different

Father's Name (for children under 18 years old)

SSN

Address if different

How did you hear about our office?

Are you currently pregnant or nursing?

Date of Last Medical Exam

Primary Physician/Clinic

Address

Phone

Date of Last Eye Exam

Clinic/Eye Doctor's Name

Do you wear glasses?

How old are your present glasses?

Do you wear a prescription Sun Wear?

Are you interested in contacts?

Do you wear contacts?

Solution Used

Wearing Schedule

Replacement Schedule

Are you interested in LASIK?

Have you ever had an eye injury?

Have you ever had eye surgeries?

Have you ever been diagnosed with?

Cataracts

When were you diagnosed?

Glaucoma

When were you diagnosed?

Macular Degeneration

When were you diagnosed?


What are your visual symptoms today?
Please indicate Right, Left or Both, along with severity 1(Low) 2(Moderate) 3(High)

Blurred Vision/Distance

Blurred Vision/Near

Double Vision

Eye Strain

Eye Infections

Eye Pain/Soreness

Tired Eyes

Burning Eyes

Itchy Eyes

Dry Eyes

Red Eyes

Watery Eyes

Mucus Discharge

Floaters or Spots

See Flashes

See Halos

Poor Night Vision

Headaches

Migraine Headaches

Loss of Vision

Crossed Eyes

Light Sensitive

Gritty Feeling

Poor Color Vision

Droopy Lid


PERSONAL MEDICAL HISTORY (REVIEW OF SYSTEMS)
Please check any of the following that applies to you, and list any medication for each condition that you check. If you have none of these conditions. Please check none.

Cardiovascular

Constitutional

Neurological

Hematological

Dermatologic

Endocrine

Ocular

Musculoskeletal

Gastrointestinal

Drug Allergies

Respiratory

Psychiatric

Immunologic

Ear/Nose/Throat

Alcohol Use

Tobacco Use

Please list physical reactions to above allergies

Please list any medications and/or drugs that you are taking (including herbal)

1. Medication

For

2. Medication

For

3. Medication

For

4. Medication

For


FAMILY HISTORY:
Has anyone in your family (grandparents, parents, siblings, children, living or deceased) been diagnosed with:

Retinal Detachment

High Blood Pressure

Diabetes

Cancer

Heart Disease

Thyroid Disease

Blindness

Cataracts

Glaucoma

Crossed Eyes

Macular Degeneration

Lupus


ADDITIONAL FORMS FOR NEW PATIENTS
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  • If you do not already have AdobeReader® installed on your computer, Click Here to download it now.

  • Download the necessary form(s), print it out and fill in the required information.

  • Fax or email us your completed form(s) or bring it with you to your appointment.

  • Downloadable New Patient Registration Form (Do not fill out if the above form was already submitted)

  • DOWNLOAD
  • Financial Information and HIPAA Notification (Download, print and fill in the required information.)

  • DOWNLOAD
  • Medical Insurance and Vision Benefits Plan (Download, print and fill in the required information.)

  • DOWNLOAD
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