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Registration Forms: Library

Prior to your appointment please fill out the online registration form below. For your convenience the form is also available for download (PDF format) for you to print, fill out, and bring with you to your first visit. (* = required)

Medical History Questionnaire
Salutation*
First Name*
Last Name*
Address*
City*
State*
Zip*
Phone*
Work Phone
Email*
Last Eye Exam
Date of Birth
Employer
Occupation
Describe how you use your vision at work so we can make the best lens recommendations for you
What kinds of hobbies, sports, and other interests do you have? Knowing this enables us to find the best vision correction for you
Who can we thank for referring you to our office
Personal History
Do you wear contacts? Yes No
If so, which type or brand?
Are you pregnant or nursing? Yes No
Have you had any major injuries, surgeries and/or hospitalizations? Yes No
If so, please list them below
Do you take any medications? Yes No
If so, please list them below
Do you currently have or had the following conditions? Check those that apply.
Allergic/Immunologic Drug Allergy Environmental Allergy Rheumatoid Arthritis
Cardiovascular Heart Disease Hypertension Stroke
Eyes Retinal Detachment Glaucoma Cataracts Macular Degeneration Lazy Eye Eye Infections Eye Injury
General Health Developmental Disability Head Trauma Headaches Cancer
Genitourinary STD - HIV, Herpes, Chlamydia
Hematologic/Lymphatic Anemia Leukemia
Dermatologic Eczema Rosacea Psoriasis
Ears, Nose Throat Ears Nose Throat
Endocrine Diabetes Thyroid
Muskuloskeletal Multiple Sclerosis Epilepsy
Psychiatric Depression
Respiratory Asthma Emphysema
Gastrointestinal Gastrointestinal
Other
Family History
Does any family member (parents, grandparents, siblings, children) currently have or had any of the following conditions? Blindess Cataract Crossed Eyes Glaucoma Macular Degeneration Retinal Detachment/Disease Cancer Diabetes Heart Disease High Blood Pressure Thyroid Disease
Other
Health History Update
Changes in medical history?
List Changes Date
Payment Policy
We will do all we can to find out what your vision insurance benefits are and what you are eligible for. We will also submit your claim for you. The information given to us by your insurance company is not a guarantee of payment from them. If your insurance company does not pay this amount it will be your responsibility to pay your balance. To the best of my knowledge, the above information is correct.
I agree*

List Changes	Date

Registration Forms: Library

Medical History Questionnaire

Personal History

Family History

Health History Update

Payment Policy

Library