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Patient Registration Form
For New & Existing Patients (Every 3x Years) | Protected by HIPAA & BAA
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* Indicates required question
ALL Data/PHI Protected by HIPAA & Google BAA
Patient First & Last Name
*
Your answer
Birthday (DOB)
*
(e.g. 04/20/1969)
Your answer
Last 4 SSN #
For Insurance Purposes Only (REMINDER: ALL of the Data & PHI on this form is Protected by HIPAA & Google BAA)
Your answer
Patient Gender
*
Female
Male
Non-Binary/Other
Other:
Email
*
Your answer
Cell Phone #
*
Your answer
Street Address
*
Your answer
Zip Code
*
Your answer
Preferred Pharmacy
*
(Name & Cross Streets)
Your answer
How did you hear about us?
Your answer
Emergency Contact
Your answer
* 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...)
Your answer
Member ID #
Your answer
VISION Insurance Co.
(e.g. VSP, Davis Vision, EyeMed, Superior Vision, Envolve...)
Your answer
Member ID #
Your answer
Primary Care Provider *or* Referring Doctor
*
(If not applicable please write "None")
Your answer
Eye Health History
*
Please indicate any EYE DISEASES /TRAUMA you have EVER been told you have:
CATARACTS
GLAUCOMA
MACULAR DEGENERATION
RETINAL TEAR / DETACHMENT
INJURY
OTHER * (Explain Below)
NONE
Required
* OTHER:
Please Explain Below...
Your answer
Please indicate any EYE SURGERIES you have had:
*
(If not applicable please mark "None")
Cataract Surgery (Both Eyes)
Cataract Surgery (Right Eye Only)
Cataract Surgery (Left Eye Only)
LASIK / RK / PRK
Glaucoma Surgery
Retinal Surgery
Other* (Explain Below)
NONE
Required
* OTHER:
Please Explain Below...
Your answer
Please indicate any systemic diseases you have EVER been told you have:
*
(If not applicable please mark "None")
Diabetes I * (If YES, please provide A1C below)
Diabetes II * (If YES, please provide A1C below)
High Blood Pressure (Hypertension)
High Cholesterol
Arthritis
Heart Disease
Thyroid
Cancer
Other*
NONE
Required
* OTHER:
Please Explain Below...
Your answer
* If replied YES, to DIABETIC, provide most recent A1C:
Your answer
Please list all Current Medications:
*
(If not applicable please write "None")
Your answer
Please list any medications you are allergic to:
*
(If not applicable please write "None")
Your answer
REASON FOR VISIT:
*
(Please check all that apply)
Glasses
Contact Lenses
Yearly Eye Health Check (Health Check Only - No Glasses Rx)
Diabetic Eye Exam
Other * / Referred by Provider: (Explain Below)
Required
* Other / Referred by Provider:
(Please write what brings you in and/or the Doctor's Office that referred you)
Your answer
Additional Comments
Your answer
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