NEW PATIENT REGISTRATION

In order to provide you the best possible care, please complete this form
and bring it to your first appointment. All information is strictly CONFIDENTIAL

Contact Information

First Name
Last Name
Daytime Phone
Mobile Phone
Email
Street Address
Suite/Apt.
City
State
Zip Code

Guardian Information (if patient is under 18 years of age)

First Name
Last Name
Daytime Phone
Mobile Phone
Email
Street Address
Suite/Apt.
City
State
Zip Code

Patient Information

Gender
Date of Birth
Social Security No.

Primary Insurance Information

Provider Name
Provider Phone
Policy/I.D. No.
Group No.

Secondary Insurance Information

Provider Name
Provider Phone
Policy/I.D. No.
Group No.

Additional Insurance Information

Provider Name
Provider Phone
Policy/I.D. No.
Group No.

Financial Assignment Information

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Acknowledgment of Notice of Privacy Practices (NPP)

  Yes, I have read the Notice of Privacy Practices (NPP) & I wish to continue my care under said terms. (NPP can be read here)

  No, I have not read this office’s NPP but I was given the opportunity to read it and declined. I wish to continue my care under said terms.

  The NPP could not be read due to the emergent nature of the care needed.
Signature agreeing to all above terms
Date


PATIENT HISTORY

Vision Correction History (please check any that apply)

Amblyopia (lazy eye)
Blurred vision at a distance
Blurred vision at near
Burning
Double vision
Drooping eyelid(s)
Dryness
Eye pain and/or soreness
Floaters or spots
Fluctuating vision
Foreign body sensation
Halos
I experience regular headaches
I stopped wearing contact lenses
I stopped wearing glasses
Infection of eye or lid
Itching
Loss of peripheral vision
Loss of vision
Mucous discharge
Redness
Sandy or gritty feeling
Sensitivity to light/glare
Strabismus (crossed eye)
Tired eyes
Watery eyes
   

Glasses History (check all that apply)


What glasses do you own?

Backup pair
Bifocals
Distance
Progressive lens
Reading
Safety glasses
Single vision
Sports glasses
Sunglasses
Trifocals

Other:

How many hours per day do you spend using a computer?

 


Check any that apply

Allergic to nickel (frames)
I do not want to wear glasses
Incorrect prescription
Need spare glasses
Need sunglasses with UV
Problems with current glasses
Problems with glare
Problems with night vision

Contact Lens History (check all that apply)

What brand of contacts do you wear?
How old are your current contacts?
How often do you replace them?
What solution do you use for soaking?
What is your typical wearing schedule?

Check any that apply
I do not want to wear contacts
Incorrect prescription
Interested in non-surgical correction
Interested in refractive laser surgery
Need spare contacts
Problems with current contacts
Would like to change my eye color

Family History (check all that apply)

Blindness
Diabetes
Eye turn/lazy eye
Glaucoma
Hypertension
Macular degeneration
   

Allergies (please list)

None

General Medical History (please answer appropriately)

When (approx.) was your last eye exam?
Primary care physician name
Primary care physician phone
list all eye conditions you have experienced:
Surgeries:

Do you have any of the following?
Arthritis
Asthma
Cancer
Diabetes
Heart disease
High cholesterol
HIV
Hypertension (high blood pressure)
Migraines/headaches
Multiple sclerosis (MS)

Other:

Referral Information


Why did you visit us?
Referred by your doctor
Visited our website
Found us on social media
Referred directly

Keep in touch
Facebook email
@Twitter handle

Questions and notes


Do you have a question? Concern? We want to know.