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Bauer Eyecare Patient Registration
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2021-09-28T16:12:16+00:00
Bauer Eyecare Patient Registration
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Consent
(Required)
Check here if you have read over the above and agree.
Name
(Required)
First
Last
Birthdate
(Required)
MM slash DD slash YYYY
Social Security Number
Email
(Required)
Marital Status
(Required)
Address
(Required)
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
Cell Phone
(Required)
Have we examined other members of your family?
(Required)
Yes
No
Occupation
Employer
Insurance Company
(Required)
Member Name
(Required)
First
Last
Member DOB
(Required)
MM slash DD slash YYYY
Member Number
(Required)
Name of Family Physician
(Required)
First
Last
How did you find out about our office?
(Required)
List all medications you are taking
(Required)
Add
Remove
Pharmacy Name
(Required)
Pharmacy Phone Number
(Required)
Medication Allergies
(Required)
Add
Remove
List All Major Illnesses, Injuries, Surgeries In The Last 10 Years
(Required)
Add
Remove
Are You Pregnant?
(Required)
Yes
No
Do You Wear Eyeglasses?
(Required)
Yes
No
Do You Wear Contact Lenses?
(Required)
Yes
No
If yes, what brand and power do you wear?
(Required)
Current Eyedrops
List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries
(Required)
Add
Remove
Family History (Family History includes your parents, grandparents, siblings, and your children)
(Required)
Blindness
Cataract
Glaucoma
Diabetes
High Blood Pressure
Cancer
Heart Disease
Thyroid Disease
Arthritis
Stroke
Macular Degeneration
None of the above
Do You Use Tobacco Products?
(Required)
Current
Previous
Never
Do You Drink Alcohol?
(Required)
Socially
Daily
Never
Patient Eye Health
(Required)
Amblyopia (lazy eye)
Blurred Vision-Far
Blurred Vision-Near
Burning Eyes
Cataracts
Double Vision
Drooping Eyelid
Dry Eyes
Eye Turn
Floaters/Spots
Fluctuating Vision
Foreign Body Sensation
Glaucoma
Glare/Light Sensitivity
Headaches
Itchy Feeling
Infection of Eye/ Lid
Loss of Vision-Central
Loss of Vision-Side
Mucus/Discharge
Redness
Retinal Detachment
Teary/Watery Eyes
None of the above
Patient General Health
(Required)
Allergies
Asthma/Respiratory
Blood Disorders
Cancer
Hypertension
Chronic Bronchitis
Chronic Cough
Diabetes
Emphysema
Gastrointestinal Problems
Heart Attack
Stroke
Headaches/Migraines
Kidney Disorders
Psychiatric/Depression
Rhuematoid Arthritis
Thyroid Disorder
Weight Loss/Gain
None of the above
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