Patient Registration Form Paperwork Submission 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:*Height*Weight (Lbs.)*Social Security Number:*Last 4 digits.Marital Status:SingleMarriedDivorcedWidowedOtherSex:*MaleFemaleEmployment StatusEmployedUnemployedRetiredOccupation: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:SingleMarriedDivorcedWidowedOtherSex:MaleFemaleEmployment StatusEmployedUnemployedRetiredOccupation:Employer:Employer Phone:Insurance InformationPrimary Insurance:Insured Name:Policy or ID #:Group #:Insured DOB: Group Name (as shown on your insurance card):Copay:Secondary Insurance:Insured Name:Policy or ID #:Group #:Insured DOB: 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?YesNoEye Health HistoryPharmacy:Phone #:Last Eye Exam:Doctor:Do you wear glasses?YesNo All the time Occasionally Reading Driving TV Do you wear contacts?YesNoTypeHours/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 InjuryYesNoFloaters 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 ConstitutionalYesNoFever, Weight Loss/GainCancerIf Cancer, List type:IntegumentaryYesNoSkin Disease/Skin CancerBreast DiseaseAcne RosaceaGastrointestinalYesNoDiarrheaConstipationCrohn's DiseaseIrritable BowelAcid Reflux/GERDNeurologicalYesNoHeadachesMigrainesSeizures/EpilepsyMusculoskeletalYesNoRheumatoid ArthritisOsteoarthritisLupusFibromyalgiaOsteoporosisEndocrineYesNoThyroid ProblemsDiabetesRespiratoryYesNoAsthmaEmphysemaCOPDEar, Nose, Mouth, ThroatYesNoRunny NoseChronic Sinus ProblemsHay FeverHearing Loss or InjuryChronic CoughDry Throat/MouthCardiovascularYesNoHypertensionChest Pain/AnginaHeart AttackCongestive Heart FailureStroke/TIAGenitourinaryYesNoProstate Cancer/EnlargedKidney DiseaseHysterectomyCervical/Ovarian CancerChronic Urinary Tract InfectionsOveractive Bladder/IncontinenceHematological/LymphaticYesNoAnemiaSickle CellBleeding DisorderHigh Cholesterol/High TriglyceridesAllergic/ImmunologicYesNoSeasonalImmune ProblemsPsychiatricYesNoDepressionMemory LossInsomniaAnxietyAlzheimer's DiseaseDementiaMedical HistoryHave you had any surgeries in the past?*YesNoList 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:GlaucomaYesNoWho:Macular DegenerationYesNoWho:CataractsYesNoWho:BlindnessYesNoWho:Retinal DetachmentYesNoWho:DiabetesYesNoWho:HypertensionYesNoWho:Do you drive?YesNoDo you use tobacco products?YesNoIf yes, type/amount/how long:Do you drink alcohol?YesNoIf yes, type/amount/how long:Do you use any other drugs?YesNoIf yes, type/amount/how long:Check if you have ever been exposed to or infected with: Gonorrhea Syphillis HIV Hepatitis Privacy PolicyHealth Information Protection* I have read and agree to the Privacy Policy Signature
