Date*

Name*

Prefix First Last

How did you hear about Eye Services?

Date of Last Vision Exam

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 No

Diabetes*

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 History

Macular 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 following

Macular 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 Information

Patient's Name*

First Last

Sex*

Address*

Street Address Address Line 2 City State Zip

Home Phone*

Work Phone

Cell Phone

Email

Texting

Yes
No

Patient Date of Birth

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

Primary

Primary Vision Insurance

Medical Insurance

Name of Policy Holder

First Last

Policy Holder D.O.B.

Relationship to Policy Holder

Policy Holder Social Security

Work Phone

Employer of Policy Holder

Secondary

Second Vision Insurance

Second Medical Insurance

Name of Policy Holder

First Last

Policy Holder D.O.B.

Relationship to Policy Holder

Policy Holder Social Security

Work Phone

Employer of Policy Holder

In Case of Emergency

Emergency Contact

Phone Number

I 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*

Patient Registration Form

Please answer the Health Questions below by checking either Yes or No

Family History

Have you ever been diagnosed with any of the following

Insurance Information

Primary

Secondary

In Case of Emergency

Eye Services of Jackson