PATIENT REGISTRATION FORM

Contact Information

This form is for print only print this form and bring it with you on your next appointment.

First Name

Middle Initial

Last Name

Address

City

State

Zip Code

Phone - -

Email Address

Personal Information

Date of Birth year
Gender Male Female

Marital Status Social Security - -

Employment Employed Student Retired Other

Insurance Company

Member's Name Policy Number

Who may we thank for referring you?

Medical History

Name of Medical Doctor

Doctor's Phone - - Date of Last Exam

Date of Last Eye Exam

Do you have any allergies to medicines? No Yes Unknown
If yes, please explain:

List any medications you take (including oral contraceptives, aspirin, over the counter medications, and home remedies)

List all major injuries, surgeries, and/or hospitalizations that you have had:

List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataract, eye infections, eye injury.

Are you pregnant or nursing? No Yes Unknown

Do you wear glasses? No Yes Unknown
If yes, how old is your present pair?

Do you wear contact lenses? No Yes Unknown
If yes, how old?

Are they comfortable? No Yes Unknown

Family History

Please note any family history (parents, grandparents, siblings, children; living or deceased) for any of the following conditions:

Social History

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor is you prefer.

Do you drive? No Yes Unknown
If yes, do you have visual difficulty while driving? No Yes Unknown
If yes, please describe:

Do you use tobacco products? No Yes Unknown
If yes, type/amount/how long?

Do you drink alcohol? No Yes Unknown
If yes, type/amount/how long?

Do you use illegaldrugs? No Yes Unknown
If yes, type/amount/how long?

Have you ever been exposed to or infected with: Gonorrhea Hepatitis HIV Syphilis

Review of Systems

Do you currently, or have you ever had any problems in the following areas?

If you answered YES to any of the above or have a condition that is not listed, please explain and list medications:

*Print this form and bring it with you on your next appointment.

We carry wide variety of designers frames for both eyeglasses and sunglasses

Learn More

PATIENT REGISTRATION FORM

Contact Information

Personal Information

Medical History

Family History

Social History

Review of Systems

We carry wide variety of designers frames for both eyeglasses and sunglasses

INFORMATION

CONTACT

732-617-1717

732-617-1313