New Patient Registration New patients must fill out our Patient Data form before a doctor can see you. WHen you press the SAVE button your data will be sent to the doctor. If you wish, you may print out a copy of the form by clicking the PRINT button. You may enter dates by clicking on the calendar icon next to the data field or you may enter a date directly into the textbox. If you enter the date into the text box it must be in the form MM/DD/YYYY. If you see a date of 02/18/1867 it means you have not entered a date in that field. SSN if you enter it must be in the from 999-99-9999. First Name and Last Name are required. WHen you are done filling in the data, press the Save button. If you have made any errors a pop up message will list them. You can then correct the named item. Once your data is correct and you press the Save button, a popup message will indicate success. If you wish to print a copy of your data, please do so after saving it first. Once you save the data it cannot be edited. If you wish to edit after saving, then press the Home button and then click the New Patient button again. If you do this within 20 minutes of the time saved it, you will be able to see your previously entered data and change it. You can then save it again. This will send multiple copies of your information to the doctor. Patient Information First Name Last Name DOB SS# (For Insurance Purposes) Address City State Zip Email Home Phone Cell Phone Work Phone Occupation Employer Spouse or Parent Name Gender Marital Status How did you hear about our office? Referral Primary Care Physician Address & Phone Number Insurance Section Please provide information for both your Medical health insurance and your Vision insurance. Vision Insurance is mainly a wellness benefit and is provided to help reduce your costs for preventive eye care while the Medical insurance exists for more serious eye problems. Responsible Party for Insurance Responsible Party for Bill Leave Message Instructions: Minor patient Lives With: Medical Insurance Section Primary Insurance Name Primary Insurance ID# Subscriber First Name Subscriber Last Name Medical Subscriber DOB Subscriber SS# Subscriber's Employer Subscriber Relation to Patient Vision Insurance Section Vision Insurance Name Vision Insurance ID# Vision Secondary Insurance Subscriber First Name Subscriber Last Name Vision Subscriber DOB Subscriber SS# Subscriber's Employer Subscriber Relation to Patient Patient Medical History General Information Please let us know the date of your last eye exam and update us about your medications, allergies to medications, major illnesses, injuries or surgeries. Last Eye Exam Date PRevious Eye Doctor Reason for Visit Do you wear contacts? Do you wear glasses? Are you interested in Contacts for the first time? List any medications you currently take (both Rx and over-the-counter) Check if you have allergies to any medicine? If checked above then list the medications here. Check if you have or had any MAJOR ILLNESSES (glaucoma, diabetes, high blood pressure, heart attack, etc.) or INJURIES (concussions, etc.) If checked above list Illnesses or Injuries: Check if you have or had any SURGERIES (cataract, appendectomy, hysterectomy, etc.) If checked above list any SURGERIES you have had: Current Problems Do you currently have any problems in the following areas? If yes, please check the appropriate box and then fill in the details by entering information in the supplied space. EYES (poor vision, dry eyes, eye pain, tearing, redness, etc.) If checked above list details here. CONSTITUTIONAL CHANGES (fever, heat stroke, weight gain or loss, unusually tired, etc.) If checked above list details here. EARS, NOSE, THROAT (hard of hearing, stuffy nose, ear ache, cough, dry mouth, etc.) If checked above list details here. CARDIOVASCULAR (high blood pressure, racing pulse, etc.) If checked describe here. RESPIRATORY (congestion, wheezing, short of breath, etc.) If checked describe here. GASTROINTESTINAL (stomach upset, diarrhea, constipation, hernia, ulcers, etc.) If checked describe here. GENITOURINARY (kidney, bladder, painful urination, frequent urination, impotence, yellow jaundice, etc.) If checked describe here. FEMALES: Are you pregnant? Nursing? If checked describe here. MUSCLES, BONES, JOINTS (joint pain, stiffness, swelling, cramps, arthritis, etc.) If checked describe here. SKIN (pimples, warts, growths, rash, etc.) If checked describe here. NEUROLOGICAL (numbness, headache, seizures, paralysis, etc.) If checked describe here. PSYCHIATRIC (anxiety, depression, insomnia) If checked list or describe here. ENDOCRINE (diabetes, hypothyroid, etc.) If checked list here. BLOOD/LYMPH (bleeding, cholesterolemia, anemia, problems related to blood transfusions, etc.) If checked describe here. ALLERGIC / IMMUNOLOGIC (sneezing, swelling, redness, itching, hives, lupus, etc.) If checked then describe allergies here. Family History Family history pertains to your mother, father, grandparent and sibling. If any member of your family has or had any of the following diseases, please check that item. Blindness Cataract Glaucoma Diabetes Hypertension Heart Disease Stroke Cancer Thyroid Disease Arthritis Any other inheritable disease? If checked, describe any other inherited disease(s). Social History Check here if your vision limits any activities of daily living (driving, reading, sports, work, etc.) Check here if you have ever had a blood transfusion. Do you drink alcohol? If checked, describe how much and how often. Do you smoke? If checked, describe how much and how often. You may click the PRINT button to print a local copy of this data. If you already saved it you do not have to save it again unless you wish to update what you entered. Home
