Patient Registration Form

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.

Due to limitations of this CMS, direct replication of interactive form fields is not possible. Below is a representation of the information requested in this form.

Patient Information

This section would typically contain form fields for collecting information such as name (prefix, first, last, suffix), address (street, line 2, city, state, zip, country), phone number, daytime phone, cell phone, and email address.

Personal Information

This section would typically contain form fields for collecting personal information such as gender, date of birth, social security number (last 4 digits), preferred language, race, ethnicity, marital status, employment status, employer, occupation, how you were referred, and communication preference.

Eye History

This section would typically contain checkboxes for current eye conditions, such as: 'I stopped wearing glasses', 'Headaches', 'Dryness', 'Blurred Vision', 'Double Vision', and more.

Glasses History

This section would typically contain a radio button question: 'Do you wear glasses?'

Contact Lens History

This section would typically contain a radio button question: 'Do you wear contact lenses?'

Medical History

This section would typically contain fields for medical history, including dates of last eye/physical exams, primary care physician, alcohol/smoking habits, and text areas for listing medical conditions, eye conditions, family medical history, surgeries, medications, and drug allergies, along with checkboxes for general health conditions.

Primary Insurance

This section would typically contain a notice: 'Please bring all insurance cards with you to your appointment', followed by fields for insurance company name, phone number, address, insured's name, identification number, group number, insured's date of birth, and patient's relation to insured.

Secondary Insurance

This section would typically contain a radio button question: 'Do you have secondary insurance?'

Comments

This section would typically contain a text area for any additional comments: 'If you have any comments you would like to add, please enter them here.'

Privacy Policy

This section would typically contain a checkbox with a link to the Privacy Policy. Example: I have read and agree to the Privacy Policy

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