Vision North SAMPLE Form

Welcome to our Office

Paperwork is an unavoidable part of the patient registration process. To expedite the process please complete as much of this form as possible and submit it at least 24 hours before your appointment. If you'd prefer to fill out the form in-office please arrive 10 minutes prior to your scheduled appointment. We thank you in advance for your time and look forward to meeting you!

General Information

Name

First Last

Patient Date of Birth

Sex

Male
Female

Address

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

Home Phone

Cell Phone

Email Address

Occupation/Grade

Spouse/Parents Name

Preferred Pharmacy

Name

Address of Pharmacy

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

Insurance Information

Vision Insurance (if applicable) - all information requested is used to verify benefits and coverage.

Vision Service Plan (VSP)
EyeMed
Other

If Other, please specify

Subscriber Name:

Subscriber Date of Birth

Subscriber ID number:

Subscriber's Last 4 digits of SSN:

Medical Insurance

If Other, please specify

Subscriber's Name

Subscriber Date of Birth

ID Number from Insurance Card

Primary Care Physician

Name of Primary Care Physician

Address of Physician's Office

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

List other specialist's here

Patient Medical and Ocular History

Have you been diagnosed or treated for any of the following?

If Other, please specify

Are you currently pregnant or nursing?

Yes
No - OR - Not Applicable

When did you last have your eyes examined?

< 1 year ago
> 1 year ago
Never

Please list any history of eye injury or surgery

I don't have a history of eye injury or surgery
I have a history of eye injury or surgery

Please specify

Do you have? (Please select all that apply)

Glasses
Contacts
Dry Eye
Floaters/Black Spots in vision
Headaches
Light Sensitivity
Lazy Eye
Reading Problems
Other

If other, please specify

Do you wear contact lenses?

Yes, I wear contact lenses
No, I don't wear contact lenses
I don't wear contact lenses, but I would like to!

What brand of contacts do you wear?

Are you interested in hearing about Laser Vision Corrections (i.e. LASIK)?

Yes
No

Have you been diagnosed with or treated for any of the following? (Please select all that apply)

Cataract
Macular Degeneration
Glaucoma
Retinal Detachment
Lazy Eye
Iritis/Uveitis
Other

If other, please specify

Are you currently taking any medications?

Yes
No

This includes eye drops, vitamins and birth control

If you are taking medications, please specify which

Allergies to medications

Yes
No

What medications are you allergic to?

Are you a tobacco user?

Yes
No
Used to be a tobacco user

Family Medical/Eye History

Do you have a family history of the following conditions? If yes, please list your relationship to the family member.

Family Medical/Eye History (CHECK ALL THAT APPLY)

If other, please specify

Please list your relationship to the family members diagnosed with the conditions above.

In a few words, describe the reason for your appointment

Last, but not least, how did you hear about us?

Name of person who referred you

If other, please specify

VISION NORTH: Dr. Paul M. Cangiano and Dr. Cayla M Bergstrom (1)

Welcome to our Office

General Information

Preferred Pharmacy

Insurance Information

Primary Care Physician

Patient Medical and Ocular History

Family Medical/Eye History