Vision Care Associates Patient Registration Form

Name*

Prefix First Middle Last

Gender*

Preferred Name

Address*

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

Social Security Number*

Date of Birth*

Email*

Home Phone*

Cell Phone*

Day Phone

Preferred phone number*

Emergency Contact*

First Last

What is their relationship with you?*

Emergency Phone*

Race*

Ethnicity*

Preferred Language*

Height*

Weight*

How were you referred to our office?*

Primary Care Physician and Clinic Name*

Address

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

Phone Number*

Fax Number

Current Medications*

Allergies*

What is the reason for today's visit?*

When was your last eye exam?*

Do you currently wear glasses or contacts?*

Yes
No

If contacts, what brand?

Are you happy with your current brand of contacts?

Do any of the following apply to you?*

Do you currently smoke?*

Yes
No

If yes, how much/often?

If you are not a current smoker have you previously smoked?

Yes
No

When did you quit?

Do you chew tobacco?*

Yes
No

If yes, how often?

Do you drink?*

Yes
No

If yes, how often?

Do you use illegal drugs?*

Yes
No

Do you engage in regular exercise?*

Yes
No

Do you take nutritional supplements (vitamins)?*

Yes
No

Do any of the following apply to you?*

Please explain the issues*

Past illness or injuries*

Past Surgeries*

Current Occupation*