Elk Grove 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*

Date of Last Exam

Patient Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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)

Do you experience?

Current Medications

(Rx or Over the Counter)

Check all that apply

Antihistamines
Diuretics (water pill)
Blood Pressure
Eye Drops
Oral Contraceptive
Thyroid

Other Medications

Name of Physician

First Last

Family Medical History

Blindness
Cataracts
Glaucoma
Diabetes
Heart Disease

Other

How did you first hear about our office?

Name

Elk Grove Optometry New Patient Registration

Welcome to Our Office

Medical History

Current Medications

Family Medical History

How did you first hear about our office?