Welcome to our online check in. Filling out the following form will allow us to make your visit to our office more efficient and give us the chance to look into your insurance coverage before your appointment. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name*

Prefix First Last Suffix

Address*

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

Phone Number*

Please provide a telephone number, with area code, so we can contact you.

Daytime Phone

Cell Phone

Email Address

Please provide us your email address.

Personal Information

Gender*

Female
Male

Date of Birth*

Social Security Number (last 4 digits only!)

Preferred Language*

Race*

Employer

How were you referred to our office?

Communication Preference

Eye History

Primary reason for visit.

Glasses History

Do you wear glasses?*

Yes
No

What types of glasses do you currently wear?

Other glasses:

Please tell us what other kinds of glasses you own.

How many hours a day do you use a computer?

Please enter a number from 0 to 24.

How many inches away, approximately, do you sit from your computer monitor?

Please enter a number from 0 to 120.

Please check off any current conditions you suffer from

I am having problems with my current glasses
There are times when I would rather not be wearing glasses
I have problems with glare
I have problems with night vision
I am allergic to nickel (e.g. frames of glasses)
I don’t have spare set of glasses
My spare glasses have an incorrect prescription
My sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Do you wear contact lenses?*

Yes
No

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

Please enter a number from 0 to 24.

What is your typical wearing schedule? In days per week:

Please enter a number from 0 to 7.

Please check off all that apply to you

I am having problems with my current contact lenses
There are times when I would rather not be wearing contact lenses
I am interested in changing or enhancing my eye color
I am interested in a non-surgical method of vision correction
I am interested in refractive laser surgery
I don't have a spare set of contact lenses
My spare contact lenses have an incorrect prescription

Medical History

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol?

Do you smoke?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list all hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all drug allergies you have

Please check off any current conditions you suffer from

Primary Insurance

Please bring in any and all insurance and vision plan cards for us to put into your records. It is important for us to be able to help you maximize your coverage.

Insurance ID Number*

Group Number

Insurance Company Name

Insurance Company Phone Number

Name of primary policy holder

First Last

Primary policy holders date of birth

Relationship to primary policy holder

Secondary Insurance

Do you have secondary insurance?

Yes
No

If you have coverage through another plan/organization, please fill in the details below.

Insurance Company Name

Insurance Company Phone Number

Name of primary policy holder

First Last

Identification Number

Group Number

Primary policy holders date of birth

Relationship to primary policy holder

Comments

If you have any comments you would like to add, please enter them here.

Privacy Policy

Click link to view our HIPAA ploicy*

I have read and agree to the Privacy Policy

Name

This field is for validation purposes and should be left unchanged.

Patient Registration Form