Freestone Optometric Center New Patient Registration

Today's Date*

Name*

First Last

Birthdate*

Patient Social Security Number*

Email*

Marital Status*

Address*

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

Home Phone*

Cell Phone*

Business Phone*

Name of Parent or Spouse*

First Last

Occupation*

Employer*

Type of Insurance*

If "Other" please specify:

Method of Payment*

Member Name

First Last

Member DOB

Member Number

Emergency Contact Name*

First Last Relationship

Emergency Phone:*

How Did You Find Out About Our Office*

List All Medications You Are Taking*

Medication Allergies*

List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries*

Do You Use Tobacco Products?*

Current
Previous
Never

Do You Drink Alcohol?*

Socially
Daily
Never

Do You Use Recreational Drugs?*

Socially
Daily
Never

Patient Eye Health*

Patient Cardiovascular Health*

Vascular Disease
Hypertension
Diabetes
Heart Pain
None of the Above

Ear/Nose/Throat*

Ear Infection
Sore Throat
Sinus Problems
Congestion
Allergies/Hayfever
Loss of Hearing
None of the Above

Are you interested in:*

Glasses
Contact Lenses
Refractive Surgery
Sunglasses
Back-up Glasses
Computer Glasses

Hobbies:*

Golf
Fishing
Raquetball/Tennis
Basketball
Sewing
Water Sports
Skiing
Piano
Other

Hobbies: Other:

Would you like to know more about:*

I authorize the release of any medical or other information necessary to process my insurance claim. I also authorize payment of benefits to Gary M. Freestone O.D.. I understand that I will be financially responsible for payment of all charges, co-payments, and deductibles incurred for services rendered from his office, that may not be covered by my insurance provider. I also understand that delinquent accounts will be sent to collections.*