Artisan Eyeworks Patient Registration

Name

First Last

Preferred Name

Primary Phone

Last 4 SSN #

Email

Date of Birth

Parent or Guardian (if patient is under 18)

First Last

Please tell us about how you heard about us

Primary Medical Care Physician

Referring Physician

Please list any current or past eye problems

List any eye surgeries and/or injuries

List any eye drops you are currently using

Allergies to medications

List all medications

Pregnant
Tobacco Use
Alcohol
Past Smoker
Current Smoker ?

Has a family member ever been diagnosed with glaucoma?

Has a family member ever been diagnosed with macular degneration?

Please check all of the following that apply to you only

Payment: All co-payments and deductibles must be paid at the time of service. Please be aware that some of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. Payment for such services will be due after your insurance is billed.

Patient Signature

Date