Elite Vision Care Patient Registration – Patient Registration Forms

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Elite Vision Care Patient Registrationadmin2017-11-10T16:57:37+00:00

Elite Vision Care Patient Registration

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birthdate*
MM slash DD slash YYYY
Email*
Social Security Number
Marital Status*
Home Phone
Cell Phone*
Business Phone
Occupation
Employer
Medical Insurance Company*
Subscriber Name*
First Last
Subscriber DOB*
MM slash DD slash YYYY
Subscriber Member ID Number*
Vision Insurance Company*
Subscriber Name*
First Last
Subscriber DOB*
MM slash DD slash YYYY
Subscriber Member ID Number*
List All Medications You Are Taking*
Medication Allergies*
List All Major Illnesses, Injuries, Surgeries In The Last 10 Years*
Are You Pregnant?*
- Yes
- No
Do You Wear Eyeglasses?*
- Yes
- No
Do You Wear Contact Lenses*
- Yes
- No
Current Eyedrops
List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries*
Patient Eye Health*
- 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
- Tearing/Watery Eyes
- None of the Above
Patient General Health
- Allergies
- Asthma/Respiratory
- Blood Disorders
- Cancer
- Hypertension
- Chronic Bronchitis
- Chronic Cough
- Diabetes
- Emphysema
- Gastrointestinal Problems
- Heart Attack
- Stroke
- Headaches/Migraines
- Kidney Disorders
- Psychiatric/Depression
- Rheumatoid Arthritis
- Thyroid Disorder
- Weight Loss/Gain
- None of the Above

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