Bauer Eyecare Patient Registration

Click Here To View The Payment Agreement

Consent(Required)
Name(Required)
MM slash DD slash YYYY
Address(Required)
Have we examined other members of your family?(Required)
Member Name(Required)
MM slash DD slash YYYY
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)