Patient Resources

At Washington Eye Doctors, we aim to make it fast and easy for our patients to know what’s going on with their eyes, and to get the fantastic eye care or custom, curated eyewear they need!

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New to Washington Eye Doctors? Register Below:

Please fill out this form so we have all your information and can focus on your care right away!

Prefix

First(Required)

Last(Required)

Suffix

Address

Street Address(Required)

Address Line 2

City(Required)

State / Province / Region(Required)

Zip / Postal Code(Required)

Country(Required)

Contact Info

Phone Number(Required)

Daytime Phone

Cell Phone(Required)

Email Address(Required)

Communication Preference

Personal Information

Gender(Required)

Female

Male

Date of Birth(Required)

MM slash DD slash YYYY

Preferred Language(Required)

Race(Required)

Ethnicity(Required)

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?(Required)

Full Social Security Number(Required)

Eye History

Please check off any current conditions you suffer from:

I stopped wearing glasses

I stopped wearing contact lenses

Headaches

Glare/light sensitivity

Tired eyes

Amblyopia (lazy eye)

Burning

Dryness

Watery Eyes

Eye pain and/or soreness

Foreign body sensation

Infection of eye or lid

Itching

Mucous discharge

Drooping eyelid(s)

Redness

Sandy or gritty feeling

Strabismus (crossed eyed)

Blurred vision at distance

Blurred vision at near

Halos

Double vision

Floaters or spots

Fluctuating vision

Loss of vision

Loss of side vision

Glasses / Contact Lens History

Do you wear glasses?(Required)

Yes

Do you wear contact lenses?(Required)

Yes

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, etc.):

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:

Chronic fever, unexpected weight loss/gain, fatigue

Ear/nose/throat problems (e.g. hearing loss, sinus problems, sore throat)

Heart problems (e.g. chest pain, irregular heart beat, swelling of feet, cold hands or feet)

Respiratory problems (e.g. shortness of breath, wheezing, coughing)

Gastrointestinal problems (e.g. heartburn, abdominal pain, diarrhea, vomiting)

Genitourinary problems (e.g. painful urination, blood in urin, sex organ problems)

Musculoskeletal problems (e.g. muscle aches, joint pain, swollen joints)

Skin problems (e.g. rashes, excessive dryness, growths or lumps)

Neurological problems (e.g. numbness, weakness, headaches, "blackouts")

Psychiatric problems (e.g. depression, anxiety)

Endocrine problems (e.g. frequent urination, thirst, feeling hot or cold all the time)

Blood/lymph problems (e.g. bruising, weakness, unusual paleness, swollen glands)

Immune problems (e.g. frequent infections, allergic reactions to foods, dust, pollens)

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insurance Company Phone Number

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Insured's First Name

Insured's Last Name

Identification Number

Group Number

Insured's Date of Birth

MM slash DD slash YYYY

Patient's Relation to Insured

Upload the front of your insurance card

Max. file size: 50 MB.

Upload the back of your insurance card

Max. file size: 50 MB.

Secondary Insurance

Do you have secondary insurance?

Yes

Insurance Company Name

Insurance Company Phone Number

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Insured's First Name

Insured's Last Name

Identification Number

Group Number

Insured's Date of Birth

MM slash DD slash YYYY

Patient's Relation to Insured

Upload the front of your insurance card

Max. file size: 50 MB.

Upload the black of your insurance card

Max. file size: 50 MB.

Comments

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Convenient Locations to Serve You & Your Family

We can’t wait to help you and your family see clearly, whether you stop by during your workday in downtown Washington, D.C., or come with your children to our convenient Chevy Chase, MD, office or Arlington, VA, locale.