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Hours & Location
Our Eye Care Center
- Meet the Doctor
Eye Care Services
Eyeglasses & Contacts
- Contact Lenses
Insurance: Covering Your Eye Care

Hours & Location
Our Eye Care Center
- Meet the Doctor
Eye Care Services
Eyeglasses & Contacts
- Contact Lenses
Insurance: Covering Your Eye Care

Directly across from Barnett and Swann Furniture, Hwy 72, Athens, Alabama

Request an Appointment

Call Now! 256-232-2409

Hours & Location
Our Eye Care Center
- Meet the Doctor
Eye Care Services
Eyeglasses & Contacts
- Contact Lenses
Insurance: Covering Your Eye Care

Hours & Location
Our Eye Care Center
- Meet the Doctor
Eye Care Services
Eyeglasses & Contacts
- Contact Lenses
Insurance: Covering Your Eye Care

Home » Contact Us » Patient Registration Form

Patient Registration Form

Paperwork Submission

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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:
- 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 Information
Primary 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 History
Pharmacy:*
Phone #:*
Last Eye Exam:*
Doctor:*
Do you wear glasses?*
- Yes
- No
- All the time
- Occasionally
- Reading
- Driving
- TV
Do you wear contacts?*
- Yes
- No
Type
Hours/Day
Choose "Yes" or "No" to indicate if you have had any of the following:
*
Yes No
Bloodshot Eyes
Blurred Vision - Distance
Blurred Vision - Near
Burning Eyes
Cataracts
Color Vision, Poor
Crossed Eyes
Discharge from Eyes
Dizzy/Fainting Spells
Double Vision
Dry Eyes
Eye Infection
Eye Injury
*
Yes No
Floaters or Spots
Glaucoma
Itching Eyes
Light Sensitive
Loss of Vision
Headaches
Night Vision, Poor
Seeing Halos
Seeing Flashes
Twitching Eyelid
Vision Poor
Watering Eyes
Red Eyes

Physician's Name:*
Last Visit:*
Choose "Yes" or "No" to indicate if you have had any of the following:
System Constitutional*
Yes No
Fever, Weight Loss/Gain
Cancer
If Cancer, List type:
Integumentary*
Yes No
Skin Disease/Skin Cancer
Breast Disease
Acne Rosacea
Gastrointestinal*
Yes No
Diarrhea
Constipation
Crohn's Disease
Irritable Bowel
Acid Reflux/GERD
Neurological*
Yes No
Headaches
Migraines
Seizures/Epilepsy
Musculoskeletal*
Yes No
Rheumatoid Arthritis
Osteoarthritis
Lupus
Fibromyalgia
Osteoporosis
Endocrine*
Yes No
Thyroid Problems
Diabetes
Respiratory*
Yes No
Asthma
Emphysema
COPD
Ear, Nose, Mouth, Throat*
Yes No
Runny Nose
Chronic Sinus Problems
Hay Fever
Hearing Loss or Injury
Chronic Cough
Dry Throat/Mouth
Cardiovascular*
Yes No
Hypertension
Chest Pain/Angina
Heart Attack
Congestive Heart Failure
Stroke/TIA
Genitourinary*
Yes No
Prostate Cancer/Enlarged
Kidney Disease
Hysterectomy
Cervical/Ovarian Cancer
Chronic Urinary Tract Infections
Overactive Bladder/Incontinence
Hematological/Lymphatic*
Yes No
Anemia
Sickle Cell
Bleeding Disorder
High Cholesterol/High Triglycerides
Allergic/Immunologic*
Yes No
Seasonal
Immune Problems
Psychiatric*
Yes No
Depression
Memory Loss
Insomnia
Anxiety
Alzheimer's Disease
Dementia
Medical History
Have 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:
Hidden
Check 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 Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Signature

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Athens Eye Care Center
Athens, Alabama

256-232-2409
22894 US HIGHWAY 72
Athens, AL 35613

Click here for Directions
Hours
Monday: 8:00 AM - 5:00 PM

Tuesday: 8:00 AM - 5:00 PM

Wednesday: 8:00 AM - 5:00 PM

Thursday: 8:00 AM - 5:00 PM

Friday: 8:00 AM - 12:00 PM

Saturday: Closed

Sunday: Closed
Holiday Hours May Vary

Hours & Location
Our Eye Care Center
Eye Care Services
Eyeglasses & Contacts
Insurance: Covering Your Eye Care

Hours & Location
Our Eye Care Center
Eye Care Services
Eyeglasses & Contacts
Insurance: Covering Your Eye Care

Home
Dry Eye Treatment
Treating Diabetic Retinopathy
Contact Us
What’s New

Home
Dry Eye Treatment
Treating Diabetic Retinopathy
Contact Us
What’s New

Athens Eye Care Center - Located at 22894 US HIGHWAY 72, Athens, AL 35613. Phone: (256) 232-2409 . https://www.athenseyes.com

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