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Hours & Location
Eye Care Services
About Us
- Meet the Eye Doctor
Eyeglasses
Contact Lenses
Insurance

Home » Contact Us » Online Forms » New Patient Registration

New Patient Registration

Please complete the information below and submit the form online

This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Contact Information
Name*
Prefix First Last Suffix
Daytime Phone
Mobile Phone
Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Guardian Information (if patient is under 18 years of age)
Is patient under the age of 18?*
- Yes
- No
Name
First Last
Daytime Phone
Mobile Phone
Email
Address
Street Address Address Line 2 City State ZIP Code
Patient Information
Gender*
- Female
- Male
Date of Birth*
MM slash DD slash YYYY
Social Security Number (last 4 digits only)
Primary Insurance
Provider Name
Provider Phone
Policy/I.D. No.
Member No.
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
Provider Name
Provider Phone
Policy/I.D. No.
Member No.
Additional Insurance Information
Do you have additional insurance?
- Yes
- No
Provider Name
Provider Phone
Policy/I.D. No.
Group No.
Financial Assignment Information
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Acknowledgement agreeing to all above terms*
- I have read and agree to the above Financial Assignment Information
Acknowledgment of Notice of Privacy Practices (NPP)
Acknowledgment of Notice of Privacy Practices*
- Yes, I have read or had explained to me by this office the NPP & I wish to continue my care under said terms.
- No, I have not read this office’s NPP but I was given the opportunity to read it and declined. I wish to continue my care under said terms.
- The NPP could not be read due to the emergent nature of the care needed.
PATIENT HISTORY
Vision Correction History
Please check any that apply
- Amblyopia (lazy eye)
- Blurred vision at distance
- Blurred vision at near
- Burning
- Double vision
- Drooping eyelid(s)
- Dryness
- Eye pain and/or soreness
- Floaters or spots
- Fluctuating vision
- Foreign body sensation
- Halos
- I experience regular headaches
- I stopped wearing contact lenses
- I stopped wearing glasses
- Infection of eye or lid
- Itching
- Loss of peripheral vision
- Loss of vision
- Mucous discharge
- Redness
- Sandy or gritty feeling
- Sensitivity to light/glare
- Strabismus (crossed eye)
- Tired eyes
- Watery eyes
Glasses History
Do you wear glasses?*
- Yes
- No
What glasses do you own?
- Backup pair
- Bifocals
- Distance
- Progressive lens
- Reading
- Safety Glasses
- Single Vision
- Sports Glasses
- Sunglasses
- Trifocals
- Other
Other glasses:
Please tell us what other kinds of glasses you own.
How many hours per day do you spend using a computer?
Please enter a number from 0 to 24.
Check any that apply
- Allergic to nickel (frames)
- I do not want to wear glasses
- Incorrect prescription
- Need spare glasses
- Need sunglasses with UV
- Problems with current glasses
- Problems with glare
- Problems with night vision
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 them?
What solution do you use for soaking?
What is your typical wearing schedule?
Check any that apply
- I would like to wear contacts
- Incorrect prescription
- Interested in non-surgical correction
- Interested in refractive surgery
- Need spare contacts
- Problems with current contacts
- Would like to change my eye color
Family History
Check all that apply*
- Blindness
- Diabetes
- Eye turn/lazy eye
- Glaucoma
- Hypertension
- Macular degeneration
- None
- Other
Other Family History
General Medical History
When, approximately, was your last eye exam?
Primary care physician name
Primary care physician phone
Please list all eye conditions you have experienced:
Surgeries:
Do you have any of the following?
- Arthritis
- Asthma
- Cancer
- Diabetes
- Heart disease
- High cholesterol
- HIV
- Hypertension (high blood pressure)
- Migraines/headaches
- Multiple sclerosis (MS)
- Other
Other Medical History:
Referral Information
Why did you visit us?
- Referred by your doctor
- Visited our website
- Found us on social media
- Referred directly
Keep In Touch
Facebook email
@Twitter handle
Questions and Notes
Do you have a question? Concern? We want to know.
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

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Bay State Eye Associates

436 Broadway Village Mall
Methuen, MA 01844

Phone: 978-687-3220
Fax: 978-794-1457

Monday: 9:00 AM - 5:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 9:00 AM - 7:00 PM
Thursday: 8:00 AM - 6:00 PM
Friday: 7:00 AM - 5:00 PM
Saturday: 9:00 AM - 1:00 PM
Sunday: Closed

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Bay State Eye Associates
436 Broadway Village Mall
Methuen, MA 01844
Phone: 978-687-3220
https://www.baystateeye2020.com

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