Patient Registration Form Date* Date Format: MM slash DD slash YYYY Name* Mr.Mrs.Dr.MissMs.Rev. Prefix First Last How did you hear about Eye Services?Date of Last Vision Exam Date Format: MM slash DD slash YYYY With WhomBriefly explain the reason for your visitDo you wear Eye Glasses?YesNoAre you interested in Glasses?YesNoType of LensesDo you wear Contact Lenses?YesNoType of LensesAre you interested in Contact Lenses?YesNoType of LensesAre you interested in surgery to reduce or eliminate your dependency on glasses and/or contact lenses?YesNoPlease answer the Health Questions below by checking either Yes or NoDiabetes*YesNoHeart Abnormalities*YesNoHigh Blood Pressure*YesNoCholesterol*YesNoThyroid Problems*YesNoSkin Disorders*YesNoNeurological Problems*YesNoHIV/AIDS*YesNoKidney Problems*YesNoTB/Pneumonia*YesNoLung/Asthma Problems*YesNoHepatitis*YesNoPregnant (currently)*YesNoCancer*YesNoHay Fever*YesNoArthritis*YesNoBleeding Tendencies*YesNoProstate Problems*YesNoSinus Problems*YesNoTobacco Use*YesNoHeadaches*YesNoAlcohol Use*YesNoStomach Problems*YesNoList any current medications: Eye Drops: List any allergies to medications: Primary Care PhysicianFamily HistoryMacular Degeneration*YesNoGlaucoma*YesNoCataracts*YesNoStrabismus (lazy eye)*YesNoDiabetes*YesNoRetinal Problems*YesNoBlindness*YesNoHave you had any eye injuries or eye surgeries?If yes, please explain:Have you had any general surgeries?If yes, please explain:Have you ever been diagnosed with any of the followingMacular Degeneration*YesNoGlaucoma*YesNoRetinal Problems*YesNoStrabismus (lazy eye)*YesNoCataracts*YesNoSerious Eye Disease*YesNoDiabetes*YesNoInsurance InformationPatient's Name* First Last Sex*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Home Phone*Work PhoneCell PhoneEmail TextingYesNoPatient Date of Birth Date Format: MM slash DD slash YYYY AgeSocial Security NumberOccupationName of EmployerSpecial Visual Demands (Work or Hobbies)Do You Have Vision Insurance*YesNoDo You Have Medical Insurance*YesNoPrimaryPrimary Vision InsuranceMedical InsuranceName of Policy Holder First Last Policy 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 Holder First Last Policy 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 ContactPhone NumberI acknowledge that I have received a copy of Eye Services Notice of Privacy Practices. Please Sign I 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 assignment.Signed*Date* Date Format: MM slash DD slash YYYY