Patient Information > Register Online
 
New patients will need to fill out a registration form. You can either download the form (as an Adobe Acrobat PDF) fill it out and bring it with you to your appointment, or you can enter your information in the online form below.
Please enter as much information as you can in the fields below and then click on the "submit button" at the bottom of the page.
This Web page is running SSL technology to ensure that your information is sent securely to our server. The URL of this page should begin with "https". If it does not, please click here.


Personal Patient Information
First Name Middle Initial
Last Name    
Gender M F
Birth Date  mm/dd/yyyy
Social Security  000-00-0000
Street Address
City
State
Zipcode
Home Phone  000-000-0000
Daytime Phone  000-000-0000
Email Address
Employer (or School)
Occupation (or Grade)
How did you hear about our office?
Insurance List
Mailing
Yellow Pages
Recommend by:
Who do we notify in case of an emergency?
Name
Address
Telephone  000-000-0000
Relationship
Vision Insurance Information
First Name of Insured same first and last name as patient
Last Name of Insured    
Insurance Plan Name if other, please list
Insured ID Number    
Policy Group Number    
Medical Insurance Information
First Name of Insured same first and last name as patient
Last Name of Insured  
Insurance Plan Name  
Insured ID Number  
Policy Group Number  
Patient Medical History
What is the main reason for your visit today?
Last Eye Examination
Name of Eye Doctor
Age of Current Glasses
Last Medical Exam
Name of Primary Physician
May we send your primary physician a report of this examination? Yes No
Please list any medications you are currently taking (include any non-prescription medications)
Please list any medications you are allergic to
How many hours per day do you work on a computer?
Please list sports or hobbies that you enjoy participating in
Eye and Medical Conditions
Please check all conditions that apply
Self Relative
Glaucoma
Cataracts
Eye Disease
Retinal Disease
Asthma
Diabetes
Thyroid Problems
Heart Disease
Lung Disease
High Blood Pressure
Self
Dryness or Burning
Blurred Vision
Double Vision
Frequent Headaches
Eye Itching or Watering
Floaters or Flashes
Eye Infection
Eye Surgery
Social History
Do you smoke? Yes  No Packs per day  
Do you drink alcohol? Yes  No  
Do you use any other recreational drugs? Yes  No