Skip to content
Search for:
Home
Animas Eyecare Registration Form
Animas Eyecare Registration Form
admin
2019-11-04T18:00:11+00:00
Animas Eyecare Registration
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Work Phone
Cell Phone
Email
Social Security Number
Occupation
Employer
If minor, name of parent or guardian
Emergency Contact Name
Emergency Contact Phone Number
Date of last eye exam
Were you dilated during your last eye exam?
Yes
No
Who performed your last eye exam?
Medical Information
How is your general health?
Do you have problems with any of these systems? (check all that apply)
Eye Disease
Gastrointestinal
Nervous
Ears/Nose/Throat
Endocrine (glands)
Cardiovascular
Musculoskeletal
Blood/Lymph
Respiratory
Immunologic
Mental
If you answered yes to any of the above, please explain
If you have diabetes, please list the type and date of diagnosis
Please list any allergies (allergic to what & what happens?)
Do you get headaches?
Other health problems?
Current medications?
Please list any operations you've had
Do you use cigarettes or tobacco?
Yes
No
Do you use alcohol?
Yes
No
Do you use any other substances?
Yes
No
Name of primary care physician
Please check any in your family history
High blood pressure
Relation?
Diabetes
Relation?
Glaucoma
Relation?
Macular degeneration
Relation?
Retinal detachment
Relation?
Cataracts
Relation?
Please list any eye operations
Please list any eye injuries
Do you have glaucoma?
Yes
No
Do you have cataracts?
Yes
No
Do you have dry eyes?
Yes
No
Other eye problems?
Do you wear glasses?
Yes
No
Do you wear contact lenses?
Yes
No
If you wear contact lenses, what type?
How did you hear about us?
Phone Book
Newspaper
Friend
Insurance Plan
Other
Do you have Vision Service Plan?
Yes
No
If yes, primary insured person's name
Date of Birth
MM slash DD slash YYYY
Last 4 of Social Security Number
Medical Insurance Company Name
Policy Number
If your insurance company is not one that we bill, you will be responsible for your bill at the time of service. If you have questions regarding this, please notify the office staff. Thank you.
*
I understand that I am responsible for payment in full for all services and materials that are not covered by an insurance plan that Animas Eye Care participates with, or if I am a self pay account.
Please check the appropriate boxes below
I would like to receive a copy of the Privacy Practices.
I would not like to receive a copy of the Privacy Practices.
I would like to receive a copy of the Contact Lens Fitting Policy.
I would not like to receive a copy of the Contact Lens Fitting Policy.
Signature
Date
MM slash DD slash YYYY
Page load link
Go to Top