Patient Registration Form Paperwork Submission "*" indicates required fields Step 1 of 2 50% Please fill in completely the following patient information.Patient Information:Name:*Address:*City, State and Zip Code:*Home Phone:*Emergency Contact Number*Email Address:Other Phone:* Work Fax Pager Cell Spouse Other Phone:* Work Fax Pager Cell Spouse Date of Birth:*HeightWeight (Lbs.)Social Security Number:*Last 4 digits.Marital Status: Single Married Divorced Widowed Other Sex:* Male Female Employment Status* Employed Unemployed Retired Occupation:Employer:Employer Phone:Guarantor Information: If same as patient, click here. Name:Address:City, State and Zip Code:Home Phone:Email Address:Other Phone: Work Fax Pager Cell Spouse Other Phone: Work Fax Pager Cell Spouse Birthdate:Social Security Number:Marital Status: Single Married Divorced Widowed Other Sex: Male Female Employment Status Employed Unemployed Retired Occupation:Employer:Employer Phone:Insurance InformationPrimary Insurance:*Insured Name:*Policy or ID #:*Group #:*Insured DOB:* MM slash DD slash YYYY Group Name (as shown on your insurance card):*Copay:*Secondary Insurance:Insured Name:Policy or ID #:Group #:Insured DOB: MM slash DD slash YYYY Group Name (as shown on your insurance card):Copay:Are you currently under the care of a hospice program or in a skilled nursing facility?* Yes No Eye Health HistoryPharmacy:*Phone #:*Last Eye Exam:*Doctor:*Do you wear glasses?* Yes No All the time Occasionally Reading Driving TV Do you wear contacts?* Yes No TypeHours/DayChoose "Yes" or "No" to indicate if you have had any of the following:*YesNoBloodshot EyesBlurred Vision - DistanceBlurred Vision - NearBurning EyesCataractsColor Vision, PoorCrossed EyesDischarge from EyesDizzy/Fainting SpellsDouble VisionDry EyesEye InfectionEye Injury*YesNoFloaters or SpotsGlaucomaItching EyesLight SensitiveLoss of VisionHeadachesNight Vision, PoorSeeing HalosSeeing FlashesTwitching EyelidVision PoorWatering EyesRed Eyes Physician's Name:*Last Visit:*Choose "Yes" or "No" to indicate if you have had any of the following:System Constitutional*YesNoFever, Weight Loss/GainCancerIf Cancer, List type:Integumentary*YesNoSkin Disease/Skin CancerBreast DiseaseAcne RosaceaGastrointestinal*YesNoDiarrheaConstipationCrohn's DiseaseIrritable BowelAcid Reflux/GERDNeurological*YesNoHeadachesMigrainesSeizures/EpilepsyMusculoskeletal*YesNoRheumatoid ArthritisOsteoarthritisLupusFibromyalgiaOsteoporosisEndocrine*YesNoThyroid ProblemsDiabetesRespiratory*YesNoAsthmaEmphysemaCOPDEar, Nose, Mouth, Throat*YesNoRunny NoseChronic Sinus ProblemsHay FeverHearing Loss or InjuryChronic CoughDry Throat/MouthCardiovascular*YesNoHypertensionChest Pain/AnginaHeart AttackCongestive Heart FailureStroke/TIAGenitourinary*YesNoProstate Cancer/EnlargedKidney DiseaseHysterectomyCervical/Ovarian CancerChronic Urinary Tract InfectionsOveractive Bladder/IncontinenceHematological/Lymphatic*YesNoAnemiaSickle CellBleeding DisorderHigh Cholesterol/High TriglyceridesAllergic/Immunologic*YesNoSeasonalImmune ProblemsPsychiatric*YesNoDepressionMemory LossInsomniaAnxietyAlzheimer's DiseaseDementiaMedical HistoryHave you had any surgeries in the past?* Yes No List any surgeries that you’ve had in the past:Enter type of surgery & when.List medications you are currently taking, including eye drops:Are you allergic to any medications, if so, list:Does anyone in your immediate family (living or deceased) have the following:Glaucoma* Yes No Who:Macular Degeneration* Yes No Who:Cataracts* Yes No Who:Blindness* Yes No Who:Retinal Detachment* Yes No Who:Diabetes* Yes No Who:Hypertension* Yes No Who:Do you drive?* Yes No Do you use tobacco products?* Yes No If yes, type/amount/for how long:Have you ever used tobacco products?* Yes No If yes, type/amount/how long/when did you quit:Do you drink alcohol?* Yes No If yes, type/amount/how long:Do you use any other drugs?* Yes No If yes, type/amount/how long:This field is hidden when viewing the formCheck if you have ever been exposed to or infected with:* Gonorrhea Syphillis HIV Hepatitis None of the Above Have been exposed to Gonorrhea Yes No Are you currently infected Yes No Have been exposed to Syphillis Yes No Are you currently infected Yes No Have been exposed to HIV Yes No Are you currently infected Yes No Have been exposed to Hepatitis Yes No Are you currently infected Yes No Privacy PolicyHealth Information Protection* I have read and agree to the Privacy Policy Signature Δ
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