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Patient Registration Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Please provide a telephone number, with area code, so we can contact you.

Personal Information

Gender*

MaleFemale

Eye History

Please check off any current conditions you suffer from

I stopped wearing glassesI stopped wearing contact lensesHeadachesGlare/Light SensitivityTired EyesAmblyopia (lazy eye)BurningDrynessWatery EyesEye Pain and/or SorenessForeign Body SensationInfection of Eye or LidItchingMucous DischargeDrooping eyelid(s)RednessSandy or Gritty FeelingStrabismus (crossed eye)Blurred Vision at DistanceBlurred Vision at NearHaloesDouble VisionFloaters or SpotsFluctuating VisionLoss of VisionLoss of Side Vision

Glasses History

Do you wear glasses? *

YesNo

Contact Lens History

Do you wear contact lenses? *

YesNo

Medical History

Please check off any current conditions you suffer from

Chronic fever, unexpected weight loss/gain, fatigue Ear/nose/throat problems (e.g., hearing loss, sinus problems, sore throat) Heart problems (e.g., chest pain, irregular heartbeat, swelling of feet, cold hands or feet) Respiratory problems (e.g., shortness of breath, wheezing, coughing) Gastrointestinal problems (e.g., heartburn, abdominal pain, diarrhea, vomiting) Genitourinary problems (e.g., painful urination, blood in urine, sex organ problems) Musculoskeletal problems (e.g., muscle aches, joint pain, swollen joints) Skin problems (e.g., rashes, excessive dryness, growths or lumps) Neurological problems (e.g., numbness, weakness, headaches, "blackouts") Psychiatric problems (e.g., depression, anxiety) Endocrine problems (e.g., frequent urination, thirst, feeling hot or cold all the time) Blood/Lymph problems (e.g., bruising, weakness, unusual paleness, swollen glands) Immune problems (e.g., frequent infections, allergic reactions to foods, dust, pollens)

Patient Registration Form

Contact Info

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