Patient Registration Form
For New & Existing Patients (Every 3x Years)
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Patient's Full Name *
Birthday (DOB) *
(e.g. 04/20/1969)
Last 4 SSN #
Last 4 of Social Security Number (For Insurance Purposes Only)
Patient Gender *
Email *
Cell Phone # *
Street Address *
Zip Code *
Preferred Pharmacy *
(Name & Cross Streets)
How did you hear about us?
Emergency Contact
* INSURANCE INFORMATION *
Please provide as much detailed info as possible to help us locate your coverage.
MEDICAL Insurance Co.
(e.g. Presbyterian, United Healthcare, Blue Cross Blue Shield...)
Member ID #
VISION Insurance Co.
(e.g. VSP, Davis Vision, EyeMed, Superior Vision, Envolve...)
Member ID #
Primary Care Provider *or* Referring Doctor *
(If not applicable please write "None")
Eye Health History *
Please indicate any EYE DISEASES /TRAUMA you have EVER been told you have:
Required
* OTHER:
Please Explain Below...
Please indicate any EYE SURGERIES you have had: *
(If not applicable please mark "None")
Required
* OTHER:
Please Explain Below...
Please indicate any systemic diseases you have EVER been told you have: *
(If not applicable please mark "None")
Required
* OTHER:
Please Explain Below...
* If replied YES, to DIABETIC, provide most recent A1C:
Please list all Current Medications: *
(If not applicable please write "None")
Please list any medications you are allergic to: *
(If not applicable please write "None")
REASON FOR VISIT: *
(Please check all that apply)
Required
* Other / Referred by Provider:
(Please write what brings you in and/or the Doctor's Office that referred you)
Additional Comments
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