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The Vision Center at Cascade Park
Berenice
2022-11-02T23:31:46+00:00
The Vision Center At Cascade Park
Name:
*
First
Middle Initial
Last
Nickname
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Other
Address:
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Preferred Phone:
*
Preferred Phone:
*
home
cell
work
Alternate Phone:
Alternate Phone:
home
cell
work
Email:
Last 4 of SSN:
(Sometimes needed for insurance verification)
Who is responsible for this account?
Self (continue to insurance section below)
Other:
Name:
First
Last
Phone:
Relation to patient:
Vision Insurance Information
(Continue to Medical Insurance section)
I am not covered by a vision insurance policy
Primary Vision Insurance Company:
Subscriber Information:
Same as Patient
Name:
First
Last
DOB:
MM slash DD slash YYYY
ID number:
Last 4 of SSN:
Medical Insurance Information
I am not covered by a medical insurance policy
My medical insurance is the same as my vision insurance policy
Primary Medical Insurance Company:
Subscriber Information:
Same as Patient
Name:
First
Last
DOB:
MM slash DD slash YYYY
ID number:
Last 4 of SSN:
Secondary Medical Insurance Company:
Subscriber Information:
Same as Patient
ID number:
Last 4 of SSN:
Name:
First
Last
DOB:
MM slash DD slash YYYY
I hereby certify that the above information is correct to the best of my knowledge.
Patient/guardian signature:
Date:
MM slash DD slash YYYY
Last eye exam date (or estimate):
Do you wear glasses?
No
Yes
Glasses Type:
Single Vision
Bifocal
Trifocal
Progressive
How often do you wear your glasses?
All the time
Only for distance
Only for near
When not wearing contacts
Do you wear contact lenses?
No
Yes
If yes, what kind or brand?
Occupation:
Hobbies:
Are you having any of the following eye concerns?
Redness
Burning
Itching
Tearing
Discharge
Blurred Vision
Eyestrain
Eye Pain
Severe sensitivity to light
Headaches
Poor night vision
Bothersome night glare
Double Vision
Do you have any other eye conditions not listed above?
Do you have any history of eye injuries or surgeries?
Are you currently using any eye drops or ocular medications?
Do you have any medical conditions? If yes, please list.
Do you have:
Diabetes
Hypertension
High cholesterol
Are you currently taking any prescription medications? If yes, please list. Attach a separate list if necessary.
Do you have any allergies to medications? If yes, please list medication and reaction.
Do you use tobacco products?
No
Yes
Do you have FAMILY HISTORY of the following?
High blood pressure
Diabetes
Glaucoma
Macular degeneration
If yes, please list relationship for each condition
How did you hear about our office?
I am a previous patient of Dr. Johnson
Insurance list of providers
Google search
Mountain View High School basketball
Ridgefield Craft Brewery
Be Local
Other
If Other, please list how you heard about our office
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