Visionelle Eyecare – Existing Patient Registration

Name*

First Last

Birthdate*

Social Security Number

Email*

Marital Status

Address

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

Home Phone

Cell Phone

Business Phone

Name of Parent or Spouse

First Last

Have we examined other members of your family?

Yes
No

Occupation

Employer

Insurance Company

Member Name

First Last

Member DOB

Member Number

Name of Family Physician

First Last

What Is Your General Health Status?

List All Medications You Are Taking

Pharmacy Name

Pharmacy Phone Number

Medication Allergies

List All Major Illnesses, Injuries, Surgeries In The Last 10 Years

Are You Pregnant?

Yes
No

Name of Last Eye Doctor

First Last

Date Of Last Eye Exam

Do You Wear Eyeglasses?

Yes
No

Do You Wear Contact Lenses

Yes
No

Current Eyedrops

List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries

Family History (Family History includes your parents, grandparents, siblings, and your children)

Do You Use Tobacco Products?

Current
Previous
Never

Do You Drink Alcohol?

Socially
Daily
Never

Patient Eye Health

Patient General Health

Visionelle Eyecare - Existing Patient Registration