Online Patient Registration FormPlease 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. This form contains confidential information and is delivered to your doctor through a secure Internet connection.
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.This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Address* Street AddressAddress Line 2CityState / Province / RegionZIP / Postal Code U.S
Phone Number*Please provide a telephone number, with area code, so we can contact you.
Daytime Phone
Cell Phone
Email AddressPlease provide us your email address.
Personal Information
Gender*
Female
Male
Date of Birth*
Social Security Number (last 4 digits only!)
Preferred Language* EnglishSpanishFrenchJapaneseDecline to specify
Race* American Indian or Alaska NativeAsianBlack or African AmericanHispanicNative Hawaiian or Pacific IslanderWhiteDecline to specify
Ethnicity* Decline to specifyHispanic or LatinoNative Hawaiian or other Pacific IslanderNot Hispanic or Latino
Marital Status DivorcedLegally SeparatedMarriedSingleWidowedOther
Employment Status Employed Full-TimeEmployed Part-TimeNot EmployedOn Active Military DutyRetiredSelf-EmployedStudent Full-TimeStudent Part-TimeOther
Employer
Occupation
How were you referred to our office? Friend or FamilyFamily DoctorOphthalmologistInsurance CompanyNewspaperTelevisionRadioReceived MailingInternetOther OptometristOther
Communication Preference EmailPostalTelephone
Eye History
Please check off any current conditions you suffer from
I stopped wearing glasses
I stopped wearing contact lenses
Headaches
Glare/Light Sensitivity
Tired Eyes
Amblyopia (lazy eye)
Burning
Dryness
Watery Eyes
Eye Pain and/or Soreness
Foreign Body Sensation
Infection of Eye or Lid
Itching
Mucous Discharge
Drooping eyelid(s)
Redness
Sandy or Gritty Feeling
Strabismus (crossed eye)
Blurred Vision at Distance
Blurred Vision at Near
Haloes
Double Vision
Floaters or Spots
Fluctuating Vision
Loss of Vision
Loss of Side Vision
Glasses History
Do you wear glasses?*
Yes
No
Contact Lens History
Do you wear contact lenses?*
Yes
No
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? NoYes, 1 per weekYes, 1 per dayYes, 2 or 3 per dayYes, 4 or more per day
Do you smoke? NoYes, 1/2 a pack per dayYes, 1 pack per dayYes, more than 1 pack per day
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