3504 McPherson Eye Care – Established Patient Registration Form

Welcome Back!

We believe your success starts with your vision. Thank you for listing any updates since we last saw you!

Name*

First Last

Preferred name

Address

Street Address Address Line 2 City State ZIP Code

Home phone

Work phone

Cell phone

Email

Date of birth*

Occupation

Employer

Medical insurance company

Member ID/ Policy number

Group number

Policy holder's name (if different)

First Last

Policy holder date of birth

Policy holder social security number (Last 4)

Relationship to patient

Vision insurance/Plan company

Member number

Policy holder's name (if different)

First Last

Policy holder date of birth

Policy holder social security number (Last 4)

Relationship to patient

Name of primary care provider

Pharmacy name and location

Are you currently experiencing? (Check all that apply)

Other

Name of previous doctor if not at McPherson Eye Care

First Last

When was your last eye exam? (Approximately)

Never
Less than one year
2-3 years
3-4 years
More than 5 years

Do you wear eyeglasses?

Yes
No

When did you get them? (Approximately)

Less than one year
2-3 years
3-4 years
More than 5 years

Do you wear contact lenses?

Yes
No

What brand are the contact lenses?(if known)

How often do you replace your contact lenses?

Daily
2 Weeks
Monthly

Do you experience dryness?

Yes
No

What brand of solution do you use?

Biotrue
Clear Care
Generic
Opti-free
Revitalens

Patient eye health

Do you have or have you had any of the conditions below?

List all past eye surgeries (please include approximate date and surgeon if known)

List all eye medications you currently use (include over the counter, contact lens drops and dosages)

Patient general heatlh

Please select all that apply to you.

(Women) Are you Pregnant?

Yes
No

Due date

(Women) Are you breastfeeding?

Yes
No

List surgeries you have had in the last 10 years

Current medications and dose (include over the counter and supplements)

Family history (includes parents, grandparents, siblings, children; living or deceased)