Patient Registration Form Date* 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 MM slash DD slash YYYY With Whom Briefly explain the reason for your visit Do you wear Eye Glasses? Yes No Are you interested in Glasses? Yes No Type of Lenses Do you wear Contact Lenses? Yes No Type of Lenses Are you interested in Contact Lenses? Yes No Type of Lenses Are 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 NoDiabetes* Yes No Heart Abnormalities* Yes No High Blood Pressure* Yes No Cholesterol* Yes No Thyroid Problems* Yes No Skin Disorders* Yes No Neurological Problems* Yes No HIV/AIDS* Yes No Kidney Problems* Yes No TB/Pneumonia* Yes No Lung/Asthma Problems* Yes No Hepatitis* Yes No Pregnant (currently)* Yes No Cancer* Yes No Hay Fever* Yes No Arthritis* Yes No Bleeding Tendencies* Yes No Prostate Problems* Yes No Sinus Problems* Yes No Tobacco Use* Yes No Headaches* Yes No Alcohol Use* Yes No Stomach Problems* Yes No List any current medications: Eye Drops: List any allergies to medications: Primary Care Physician Family HistoryMacular Degeneration* Yes No Glaucoma* Yes No Cataracts* Yes No Strabismus (lazy eye)* Yes No Diabetes* Yes No Retinal Problems* Yes No Blindness* Yes No Have 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* Yes No Glaucoma* Yes No Retinal Problems* Yes No Strabismus (lazy eye)* Yes No Cataracts* Yes No Serious Eye Disease* Yes No Diabetes* Yes No Insurance 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 Texting Yes No Patient Date of Birth MM slash DD slash YYYY Age Social Security Number Occupation Name of Employer Special Visual Demands (Work or Hobbies) Do You Have Vision Insurance* Yes No Do You Have Medical Insurance* Yes No PrimaryPrimary Vision Insurance Medical Insurance Name of Policy Holder First Last Policy Holder D.O.B. MM slash DD slash YYYY Relationship to Policy Holder Policy Holder Social Security Work PhoneEmployer of Policy Holder SecondarySecond Vision Insurance Second Medical Insurance Name of Policy Holder First Last Policy Holder D.O.B. MM slash DD slash YYYY Relationship to Policy Holder Policy Holder Social Security Work PhoneEmployer of Policy Holder In Case of EmergencyEmergency Contact Phone 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* MM slash DD slash YYYY