Topa Topa Optometry Patient Registration

Today's Date

Patient Name

First Middle Last

Patient's Social Security #

Patient's Birthdate

Address

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

Home Phone

Work Phone

Cell Phone

Sex

M
F

Married
Widowed
Single
Minor
Separated
Divorced
Partnered

Occupation

Employer

Spouse's Name

Spouse's Work #

Please give our receptionist any major medical or eye insurance cards for us to photocopy.*

We are happy to see you for your visit today. We would like to inform you that without the proper insurance information, we cannot verify that your fees will be paid for by insurance. The entire balance will be your financial responsibility.
I certify that I, and/or my dependent(s) have insurance coverage that I presented and assign directly to Drs. Brockman & Tsao all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. I authorize the disclosure of my health care information as needed to process these claims.

Year of last eye exam and name of Doctor

Year of last medical exam and name of Doctor

We can photocopy a list of your medications or obtain a list from your physician if you prefer:

Medications (include vitamins), Strength/Dose, # pills per day, and the reason you are taking this medication:

Allergies to medications (Mild, Moderate, or Severe reaction: please describe):

Please list any surgeries you have had (including chemotherapy):

Which pharmacy do you prefer:

Check if you have:

High Blood Pressure
Diabetes
High Cholesterol
Heart Disease
Cataracts
Glaucoma
Macular Generation

Other:

Check if a family member has:

High Blood Pressure
Diabetes
High Cholesterol
Heart Disease
Cataracts
Glaucoma
Macular Generation

Other:

Which relative (if any)

Check if you have:

Any additional information that you would like the Doctor to be aware of:

Number of dependent children:

Number of adult children:

Are you pregnant or nursing?

Yes
No

When did you start smoking:

Never
Previously
Current Smoker

Year smoking began

Year smoking ended

Do you drink alcohol:

no
less than 1 drink per day
1-2 per day
more than 3 drinks per day

How did you hear about our office?

Your primary reason for this visit is:

Email address (this will only be used to confirm appointments, etc. and will never be shared):

Person to contact in case of emergency:

Name

First Last

Address

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

Phone

Relationship to you