New Patient Form Patient Registration Form- new Date Date Format: MM slash DD slash YYYY Name First Last Mr. Ms. Dr. Miss Rev How did you hear about Eye Services?Date of last vision exam?With whom?Briefly explain the reason for your visitDo you wear eye glasses Yes No Are you interested in glasses? Yes No Type of lensesDo you wear contact lenses? Yes No Type of lensesAre you interested in contact lenses Yes No Type of lensesAre you interested in surgery to reduce or eliminate your dependency on glasses and/or contact lenses? Yes No Please answer the Health Questions below by checking either Yes or NoYesNoDiabetesHigh Blood PressureThyroid ProblemsNeurological ProblemsKidney ProblemsLung/Asthma ProblemsPregnant (currently)Hay FeverBleeding TendenciesSinus ProblemsHeadachesStomach ProblemsHeart AbnormalitiesCholesterolSkin DisordersHIV/AIDSTB/PneumoniaHepatitis/PneumoniaCancerArthritisProstate ProblemsTobacco useAlcohol useList any current medications:Eye dropsList any allergies to medicationsPrimary care physicianFamily HistoryYesNoMacular DegenerationCataractsDiabetesBlindnessGlaucomaStrabismus (lazy eye)Retinal ProblemsHave you had any eye injuries or eye surgeries? If yes please explainHave you had any general surgeries? If yes please expainHave you been dignosed with any of the following?YesNoMacular DegenerationRetina ProblemsCataractsStrabismus (lazy eye)DiabetesGlaucomaSerious Eye DiseaseInsurance InformationName First Last SexAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell PhoneEmail Patient Date of Birth Date Format: MM slash DD slash YYYY Social Security NumberOccupationName of EmployerSpecial Visual Demands (Work or Hobbies)Do You Have Vision Insurance Yes No Do You Have Medical Insurance Yes No PrimaryPrimary Vision InsuranceMedical InsuranceName of Policy HolderPolicy Holder D.O.B. Date Format: MM slash DD slash YYYY Relationship to Policy HolderPolicy Holder Social SecurityWork PhoneEmployer of Policy HolderSecondarySecond Vision InsuranceSecond Medical InsuranceName of Policy HolderPolicy Holder D.O.B. Date Format: MM slash DD slash YYYY Relationship to Policy HolderPolicy Holder Social SecurityWork PhoneEmployer of Policy HolderIn Case of EmergencyEmergency ContactPhoneI acknowledge that I have received a copy of Eye Services Notice of Privacy Practices.Please SignI authorize the release of any medical information necessary to process insurance claims and request payment to either myself or the party who accepts assignment. I state that the information on this document is correct to the best of my knowledge. I permit a copy of these benefits to myself or the party who accepts assignments. SignatureDate Date Format: MM slash DD slash YYYY Print this form