The fields marked with a red * are required and must be completed before submitting your form.

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 or Employee ID number (last 4 digits only!)*

Enter whichever you will use towards your insurance.

Preferred Language*

Race

Ethnicity*

Marital Status

Marital Status - Other

Please provide your marital status.

Employment Status

Employment Status - Other

Please provide your employment status.

Employer

Occupation

How were you referred to our office?*

Referral Status - Other

Please let us know how you were referred to our office.

Communication Preference

Eye History

Please check off any current conditions you suffer from*

I stopped wearing glasses because:

I stopped wearing contact lenses because:

Glasses History

Do you wear glasses?*

Yes
No

What glasses do you own?

Single Vision
Bifocals
Safety Glasses
Backup Glasses
Progressive
Trifocals
Sports Glasses
Sunglasses
Other

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, high Cholesterol,etc.), put NA if nothing*

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment), NA if nothing*

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.) Put NA if nothing*

Please list all hospital surgeries you have ever had: NA if nothing

Please list all prescription and over-the-counter medications you take and for what conditions, NA if nothing*

Please list all drug allergies you have*

Please check off any current conditions you suffer from*

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insurance Company Phone Number

Address

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

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

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

Address

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

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Comments

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

Privacy Policy

Health Information Protection*

I have read and agree to the Privacy Policy

Signature*

Date*

Name

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

Patient Registration Form

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Privacy Policy

Eye Boutique Optometry Inc