Patient Registration Form

Today's Date *
Last Name *
First Name *
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Address
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Home Phone *
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Occupation
Primary Care Provider
Last Eye Exam
Are you new to our office?
Have you seen an ophthalmologist?
If yes, Who?
If yes, When?

Medical Conditions

Blurred Distance Vision
Blurred Near Vision
Frequent Headaches
Double Vision
Dry eyes
Itchy Eyes
Floaters
Recent Change in Vision
Have you ever been told you have, Prism in your glasses?
Is today’s exam for contact lenses?
Do you already wear contacts?
If so,

Medical History

Glaucoma
Personal
Family
Macular Degeneration​​​​​​​
Personal
Family
High Cholesterol
Personal
Family
High Blood Pressure
Personal
Family
Diabetes
Personal
Family
Heart Disease
Personal
Family
Amblyopia(Lazy Eye)
Personal
Family
Eye Injury​​​​​​​
Personal
Family
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Eye Surgery
Personal
Family
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Eye Surgery
Personal
Eye Surgery
Are you allergic to:
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Are you now taking any medications:
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Preferred Language
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Medical Insurance
Vision Insurance
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