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4910 LC Eye Clinic
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2020-12-17T23:20:00+00:00
4910 LC Eye Clinic
Patient Registration
Exam Date
Month
Day
Year
Name
*
First
Middle Initial
Last
Sex
Male
Female
Date of Birth
*
MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
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Preferred Phone Number
*
Phone number type
*
Home
Work
Cell
Secondary Phone Number
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Home
Work
Cell
Employer
Occupation
Referred by
Email
*
Signature
*
Insurance Information
Plan Name
Group
Insured Name
First
Last
Insured ID#
Relationship To Patient
Self
Spouse
Child
Insured Date of Birth
Month
Day
Year
Medical and Ocular
What is the reason for today's exam?
*
Are you planning to get new glasses today?
*
Yes
No
Are you planning to get new contact lenses today?
*
Yes
No
Age of present glasses
Age of sunglasses
Date of last eye exam
MM slash DD slash YYYY
From Dr.
Previous Patient?
Yes
No
Medical History
Allergies to Medications: Please List
Do you have any of the following conditions?(Select all that apply)
*
Diabetes
High Blood Pressure
Thyroid Problems
Heart Disease
Asthma
Cancer
Glaucoma
Cataracts
Retinal Disease
Eye Surgery
Eye Injury
Other
None
Do any blood relatives have any of the following conditions?(Select all that apply)
*
Diabetes
High Blood Pressure
Thyroid Problems
Heart Disease
Asthma
Cancer
Glaucoma
Cataracts
Retinal Disease
Eye Surgery
Eye Injury
Other
None
Do you see double?
*
Yes
No
Frequent Headaches?
*
Yes
No
Are you pregnant?
*
Yes
No
Eyes been dilated?
*
Yes
No
Year?
Primary Care Dr.
*
Please explain positive findings
Are you taking any eyedrops(prescription or over the counter)
*
Yes
No
Please list
*
Prescription
OTC
Are you taking any other medications?(Prescription or OTC)
*
Yes
No
Please list
*
Prescription
OTC
Do you have any allergies, medications or other?
*
Yes
No
Please explain
*
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