3504 McPherson Eye Care – New Patient Registration Form

Welcome!

We believe your success starts with your vision. Thank you for helping us prepare for your visit!

Name*

First Last

Preferred name

Address

Street Address Address Line 2 City State ZIP Code

Home phone

Work phone

Cell phone

Email

Marital status

Social security number

Date of birth*

Name of parent (If under 18)

First Last

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 eye doctor

First Last

When was your last eye exam? (Approximately)

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

3504 McPherson Eye Care - New Patient Registration Form

Step 1 of 2

Welcome!

Patient eye health

Patient general health

Social History

Please bring your:

- Insurance cards

- Glasses, sunglasses, readers and computer/hobby glasses

- Contact lens prescription, boxes or foil packs

Thank you!