Bauer Eyecare Patient Registration

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Have we examined other members of your family?(Required)
Member Name(Required)
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Name of Family Physician(Required)
List all medications you are taking(Required)
Medication Allergies(Required)
List All Major Illnesses, Injuries, Surgeries In The Last 10 Years(Required)
Are You Pregnant?(Required)
Do You Wear Eyeglasses?(Required)
Do You Wear Contact Lenses?(Required)
List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries(Required)
Family History (Family History includes your parents, grandparents, siblings, and your children)(Required)
Do You Use Tobacco Products?(Required)
Do You Drink Alcohol?(Required)
Patient Eye Health(Required)
Patient General Health(Required)