Unofficial preview: Patient Registration Form

Name (required)

Prefix

First

Last

Suffix

Address (required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone Number (required)

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

Daytime Phone

Cell Phone

Email Address

Please provide us your email address.

Gender (required)

FemaleMale

Date of Birth (required)MM slash DD slash YYYY

Social Security Number (last 4 digits only!)

Preferred Language (required)

Race (required)

Ethnicity (required)

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference

Do you wear glasses? (required)

YesNo

Do you wear contact lenses? (required)

YesNo

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?

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

Insurance Company Name

Insurance Company Phone Number

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Insured's Name

First

Last

Identification Number

Group Number

Insured's Date of BirthMM slash DD slash YYYY

Patient's Relation to Insured

Do you have secondary insurance?

YesNo

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

If you have any comments you would like to add, please enter them here.

Health Information Protection (required)

I have read and agree to the Privacy Policy

Monday	9:00 AM - 5:00 PM
Tuesday	9:00 AM - 5:00 PM
Wednesday	9:00 AM - 5:30 PM
Thursday	9:00 AM - 5:30 PM
Friday	9:00 AM - 4:30 PM
Saturday	Closed
Sunday	Closed

Patient Registration Form

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Privacy Policy

Eye Care New Braunfels