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 InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Daytime PhoneMobile PhoneEmail Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Guardian Information (if patient is under 18 years of age)Is patient under the age of 18?* Yes No Name First Last Daytime PhoneMobile PhoneEmail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient InformationGender* Female Male Date of Birth* MM slash DD slash YYYY Social Security Number (last 4 digits only) Primary InsuranceProvider Name Provider PhonePolicy/I.D. No. Member No. Secondary InsuranceDo you have secondary insurance? Yes No Provider Name Provider PhonePolicy/I.D. No. Member No. Additional Insurance InformationDo you have additional insurance? Yes No Provider Name Provider PhonePolicy/I.D. No. Group No. Financial Assignment InformationI 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 HISTORYVision Correction HistoryPlease 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 HistoryDo 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 HistoryDo 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 HistoryCheck all that apply* Blindness Diabetes Eye turn/lazy eye Glaucoma Hypertension Macular degeneration None Other Other Family HistoryGeneral Medical HistoryWhen, approximately, was your last eye exam? Primary care physician name Primary care physician phonePlease 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 InformationWhy did you visit us? Referred by your doctor Visited our website Found us on social media Referred directly Keep In TouchFacebook email @Twitter handle Questions and NotesDo you have a question? Concern? 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