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Elk Grove New Patient Registration
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2018-07-05T23:06:00+00:00
Elk Grove Optometry New Patient Registration
Welcome to Our Office
Payment is due when services are rendered. A 50% deposit is required upon ordering glasses or contact lenses.
Name
*
First
Last
Today's Date
*
MM slash DD slash YYYY
Date of Last Exam
MM slash DD slash YYYY
Patient Date of Birth
*
MM slash DD slash YYYY
Address
*
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
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
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 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
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
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 Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
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
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Gender
Male
Female
Age
*
Home Phone
Work Phone
Vision Insurance
Social Security Number
Employer (or School)
Untitled
First Choice
Second Choice
Third Choice
Occupation (or Grade)
Spouse or Parent's Name
First
Last
Spouse or Parent's Phone
How will you settle your account today?
Check
Cash
Credit Card
Medical History
Check all that apply
Allergies
Asthma
Arthritis
Cancer
Skin Disorder
Diabetes
Eye Disease
Eye Surgery
Lazy Eye
Glaucoma
Heart Disease
High Blood Pressure
Cataract
Other
Do you...(check all that apply)
Work at a computer for long periods?
Have more than one pair of glasses?
Want more information on thinner, lighter lenses?
Wear bifocals?
(if yes, are you bothered by head tilting, restricted areas of vision correction, particularly when driving at night?)
Have prescription sunglasses?
Have problems with glare or reflection, particularly when driving at night?
Have family members in need of eye care?
Smoke?
Consume alcohol?
Do you experience?
Burning
Itching
Nausea
Watery eyes
Tearing
Dryness
Eye strain
Reading Problems
Glare or reflection
Uncomfortable contact lenses
Trouble working up-close
Spots
Other
Soreness
Flashes of light
Headaches or redness
Double Vision
Uncomfortable glasses
Sudden loss of vision
Sensitivity to light
Fainting or dizziness
Blurry distance vision
Gritty feeling eyes
Objects floating in vision
Trouble seeing at night
Trouble reading or learning at work, school, or activity
Current Medications
(Rx or Over the Counter)
Check all that apply
Antihistamines
Diuretics (water pill)
Blood Pressure
Eye Drops
Oral Contraceptive
Thyroid
List Medications
Other Medications
Name of Physician
First
Last
Family Medical History
Blindness
Cataracts
Glaucoma
Diabetes
Heart Disease
List Relationship
Other
How did you first hear about our office?
Friend
Relative
Insurance Plan
Another health care practitioner
Yellow pages
Name
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