4910 LC Eye Clinic

Patient Registration

Exam Date

Name*

First Middle Initial Last

Sex

Male
Female

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Preferred Phone Number*

Phone number type*

Secondary Phone Number

Phone number type

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

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

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)*

Do any blood relatives have any of the following conditions?(Select all that apply)*

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*