VISION NORTH: Updated Patient Form

VISION NORTH: Patient History Update

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!

Updated Information

Please let us know if there have been any changes in the following information:

Name Change

Yes
No

New Name

First Last

Previous Name

First Last

Address Change

Yes
No

New Address

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

Phone Number Change

Yes
No

New Phone Number

Email Address Change

Yes
No

Email Address

Occupation/Grade

Vision Insurance Change

Yes
No

New Plan Name

New Subscriber ID

Primary Name and Date of Birth

Medical Insurance Change

Yes
No

New Plan Name

New Subscriber ID Number from Insurance Card

Primary Name and Date of Birth

Change in Your Health

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

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

Change in your current medications

Yes
No

This includes eye drops, vitamins and birth control

If yes, 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

In a few words, describe the reason for your appointment

VISION NORTH: Dr. Paul M. Cangiano and Dr. Cayla M Bergstrom Updated History Form

VISION NORTH: Patient History Update

Updated Information