Patient Registration Form

Intake Form

Name

Mailing Address

Phone Number:

Daytime Phone:

Cell Phone:

Email:

Gender:

Date of Birth:

Last 4 of SNN:

Preferred Language:

Race:

Ethnicity:

Martial Status:

Employer:

Occupation:

How were you referred to our office?

Communication Preference:

Please check off any current conditions you suffer from:

Do you wear glasses?

Do you wear contact lenses?

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol?

Do you smoke?

Do you drive?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list all hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all drug allergies you have

Please check off any current conditions you suffer from:

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