New Patient Registration Form

Step 1 of 6
First Name*
Last Name*
Date of Birth *
Home Phone
Day Phone
Cell Phone
Texting OK?
Email*
Street Address*
Address Line 2
City*
State*
ZIP*
*This field is required. Please complete the following fields: Street Address, City, State / Province, ZIP / Postal Code.
Martial Status*
Employment Status*
Preferred Language
Race
Communication Preferrence
How did you find out about us?
Step 2 of 6

Insurance Information

Insurance Company
Member ID/SSN
Group Number
Relationship to the Insured
Insured's Date of Birth
Insured's Employer
Name of insured person if not the patient

Health Insurance

Insurance Company
Member ID/SSN
Group Number
Relationship to the Insured
Insured's Date of Birth
Insured's Employer
Name of insured person if not the patient
Step 3 of 6

Medical History

Primary Care Doctor's Name
Please Explain
List any medications you take (including oral contraceptives, aspirin, over-the-counter meds and home remedies)
List any ocular medications you take.
List all major injuries, surgeries, and/or hospitalizations you have had
Check any of the following you have had
Please Explain
Step 4 of 6

Social History

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Step 5 of 6

Family History

Please note any family history (parents, grandparents, siblings, children; living or deceased) of the following
Blindness*
Cataracts*
Crossed Eyes*
Glaucoma*
Macular Degeneration*
Retinal Detachment/Disease​​​​​​​*
Arthritis​​​​​​​*
Cancer​​​​​​​​​​​​​​*
Diabetes​​​​​​​*
Heart Disease​​​​​​​​​​​​​​*
Kidney Disease*
Lupus​​​​​​​​​​​​​​*
Thyroid Disease*
Other*
Step 6 of 6

Review of System

Please check or fill in the blank if you have any of the following.
Cardiovascular
Ear, Nose, Mouth, and Throat
Musculoskeletal
Constitutional
Immunological
Neurological
Endocrine
Psychiatric
Gastrointestinal
Hematologic/Lymphatic
Integumentary
Height
Weight
Please list any conditions not listed above.

Please sign below to give authorization for and agree to the following:

Release of your exam findings to your insurance company for reimbursement.

Release of medical information to other doctors/health care professionals when a referral is indicated.

Co-Pays and fees must be paid by cash or credit card at the time of your visit.

Not all medical services are covered under your insurance policy. You are responsible for services that your insurance company (including Medicare) classifies as “non-covered” services.

Are you a parent or guardian of the patient?*
Signature*