Eye See Optometry – Patient Registration Forms

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Eye See Optometryadmin2017-07-06T01:14:23+00:00

Eye See Optometry

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Contact Information
Name*
First Last
Phone*
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Guardian Information
(if patient is under 18 years of age)
Name
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient Information
Gender*
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number*
Primary Insurance information
Provider Name
Provider Phone
Provider/I.D. No.
Group No.
Secondary Insurance information
Provider Name
Provider Phone
Provider/I.D. No.
Group No.
Additional Insurance information
Provider Name
Provider Phone
Provider/I.D. No.
Group No.
Financial Assignment Information
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Acknowledgment of Notice of Privacy Practices (NPP)
- Yes, I have read or had explained to me by this office the NPP & I wish to continue my care under said terms.
- No, I have not read this office’s NPP but I was given the opportunity to read it and declined. I wish to continue my care under said terms.
- The NPP could not be read due to the emergent nature of the care needed.
Signature agreeing to all above terms
Date
Date Format: MM slash DD slash YYYY

Vision Correction History
please check any that apply
- Amblyopia (lazy eye)
- Blurred vision at a distance
- Blurred vision at near
- Burning
- Double vision
- Drooping eyelid(s)
- Dryness
- Eye pain and/or soreness
- Floaters or spots
- Fluctuating vision
- Foreign body sensation
- Halos
- I experience regular headaches
- I stopped wearing contact lenses
- I stopped wearing glasses
- Infection of eye or lid
- Itching
- Loss of peripheral vision
- Loss of vision
- Mucous discharge
- Redness
- Sandy or gritty feeling
- Sensitivity to light/glare
- Strabismus (crossed eye)
- Tired eyes
- Watery eyes
Glasses History
- Backup Pair
- Bifocals
- Distance
- Progressive lens
- Reading
- Safety glasses
- Single vision
- Sports glasses
- Sunglasses
- Trifocals
- Other
What glasses do you own? Check all that apply
- Allergic to nickel (frames)
- I do not want to wear glasses
- Incorrect prescription
- Need spare glasses
- Need sunglasses with UV
- Problems with current glasses
- Problems with glare
- Problems with night vision
Check any that apply
Other:
How many hours per day do you spend using a computer?
Please enter a number from 0 to 24.
Contact Lens History
What brand of contacts do you wear?
How old are your current contacts?
How often do you replace them?
What solution do you use for soaking?
What is your typical wearing schedule?
Check any that apply
- I do not want to wear contacts
- Incorrect prescription
- Interested in non-surgical correction
- Interested in refractive laser surgery
- Need spare contacts
- Problems with current contacts
- Would like to change my eye color

Family History
Check all that apply
- Blindness
- Diabetes
- Eye turn/lazy eye
- Glaucoma
- Hypertension
- Macular degeneration
Allergies
Please list
- None
List:
General Medical History
When (approx.) was your last eye exam?
Primary Care physician name
Primary Care physician phone
Please list all eye conditions you have experienced:
Surgeries:
Do you have any of the following?
- Arthritis
- Asthma
- Cancer
- Diabetes
- Heart disease
- High cholesterol
- HIV
- Hypertension (high blood pressure)
- Migraines/headaches
- Multiple sclerosis (MS)
- Other
Other:
Referral Information
Why did you visit us?
- Referred by your doctor
- Visited our website
- Found us on social media
- Referred directly
Keep in touch
Facebook email
@Twitter handle
Questions and notes
Do you have a question? Concern? We want to know.

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