| Patient
Registration Form
Patients often dread the uncomfortable experience
of sitting in a doctor's waiting room with a
clipboard, their medicine list, and all of their
insurance cards in their lap trying to fill
out the patient registration form while others
look on. This page's purpose is to help you
avoid that scenario. You can print this page
and fill it out in the comfort of your own home,
or, if you like, you can e-mail it to our office
before your visit. Please complete this form
as completely and accurately as possible.
* = required fields |
| Name* |
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Address*
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| City* |
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| State* |
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| Zip* |
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| E-mail Address |
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| Alternate E-mail |
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| Home Phone Number* |
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| Work Phone Number* |
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| Occupation* |
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| Employer* |
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| Age* |
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| Race* |
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| Sex* |
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| Date of Birth* |
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| Social Security Number |
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| Marital Status |
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| Spouse's Name |
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| Spouse's Employer |
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| Spouse's Work Phone Number |
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| Emergency Contact* |
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| Emergency Phone Number* |
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| Medical
Insurance Information
Medical insurance covers medical eye problems,
such as infections, glaucoma, eye problems due
to diabetes, cataracts, dry eye, and eye injuries.
Please list your primary and secondary insurance
carriers below and bring your cards with you
to our office so that we may copy them. |
| Do you have medical insurance*? |
Yes
No |
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| Vision
Plan Insurance Information
Vision Plans cover well patient eye care and
vision problems such as nearsightedness, astigmatism,
farsightedness, or the need for bifocals. They
also often pay all or part of the cost of eyeglasses
or contact lenses (or at least offer you a discount
in many cases). Please bring your vision plan
cards or forms with you so that we may verify
your benefits. |
| Do you have vision insurance*? |
Yes
No |
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| Eye Health
History |
| When was your last eye exam? |
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| Which eye doctor did you see
last? |
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| Please choose
the appropriate response from the questions below*. |
| Bloodshot,
Red Eyes?
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Other?
If yes, please describe below.
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| Blurred
Distance Vision?
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| Blurred
Near Vision?
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| Burning
Eyes?
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| Cataracts?
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| Poor color
vision?
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| Crossed
Eyes?
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| Discharge
from Eyes?
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| |
| Medical History |
| Are you taking
any medications*? |
Yes
No |
| If
"Yes", please list below:
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| Do you have any allergies*? |
Yes
No |
| If
"Yes", please list below:
|
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| Signature
on File:
I authorize use of this form on all of my insurance
submissions and the release of information to
my insurance company. I understand that I am
responsible for my bill. I authorize payment
directly to my doctor. I permit a copy of this
authorization to be used in place of the original. |
Signature |
/
/
Date |
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