Patient Registration Form Name* Mr.Mrs.Ms.MissDr.Other Prefix First Last Provide your legal nameDate of Birth* Age*Preferred Language:EnglishSpanishRace:American Indian or Alaska NativeAsianBlack or AfricanHispanicNative Hawaiian/Pacific IslandWhiteEthnicity:Hispanic or LatinoNative Hawaiian/Pacific IslandNot Hispanic or LatinoCommunication, Preferred:*EmailPostalTelephoneIf Child, Name of Parent/GuardianSchool GradeAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneSoc. Sec. #Cell PhoneFax #E-mail* Referred byEmployerOccupationEmployment Status: Full-time Part-time Student Unemployed Marital Status:MarriedSingleWidow/WidowerDomestic PartnerGeneral Health Insurance Company Name:Health Insurance Group Number:Health Insurance Member ID Number:Relationship to Insured:SelfSpouseDependent/ChildIf insured is spouse, name of spouse:Vision Insurance Company Name:Reason for this Examination:Do you have, or is there any family history of:SelfFamilyGlaucomaHeadachesDouble VisionCataractsFlashes, FloatersEye discomfort/IrritationEye SurgeryEye Head InjuryBlindnessEye Exercises/ Vision TrainingHeart/Vascular ProblemsReading difficultyHypertensionDiabetesArthritisSudden Vision LossAllergiesOtherIf other, please specify:Are there any other general health or eye problems that you wish to discuss:Do you use cigarettes/tobacco?YesNoAlcohol?YesNoOther Substance(s)?Are you pregnant or nursing?YesNoList any medications, vitamins, shots, etc that you presently take: Date of last eye examination DoctorCityName of regular physicianCityDo you presently wear glasses?YesNoIf Yes, age of present prescriptionDo you wear contact lenses?YesNoIf Yes, how old are they? Right Left Did you ever try contact lenses?YesNoIf Yes, why did you stop? - Professional fees are due when service is rendered. - Eyewear must be paid for in full when ordered. - There is a $25.00 fee for all returned checks. - A collection fee equal to 35% of the balance due will be added to all accounts referred for collection services. - Patients are responsible for all charges not paid by their insurance carriers. - The practice reserves the right to charge for cancelled or missed appointments with less than 24 hours notice. By signing below, I agree to the INSURANCE AUTHORIZATION POLICY, and have read and understood the NOTICE OF PRIVACY PRACTICES and ACKNOWLEDGEMENT. (Clicking on the following 3 links will open these documents as PDFs for you to read.) INSURANCE AUTHORIZATION POLICY NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENTSignatureIf you have questions about any of the following, please mark with a check:Contact Lenses Soft Gas Permeable Disposable Bifocal Tinted Astigmatic Extended Wear Glasses No-line Bifocals Ultra-thin Lenses Prescription Sunglasses Photochromic Lenses Tints, Coatings U.V. Protection Sports Glasses Computer Eyewear Children's Vision Swimming with Contact Lenses Protective Eyewear Laser Vision Correction Other If other, please specify:So that we may better meet your vision needs, please complete this lifestyles questionnaire. Please check the activities you MOST OFTEN participate in.Name First Last AgePlease select:MFSports basketball softball/baseball tennis gymnastics golf raquetball hockey volleyball skiing soccer swimming hunting football fishing bowling water-skiing other If other, please specify:Physical Fitness aerobics martial arts biking jogging walking rollerblading dancing other If other, please specify:Social/Hobby gardening musical instrument crafts evening out travel movies sewing computers boating snowmobile jet ski other If other, please specify:Business presentations interviews travel computer other If other, please specify:YesNoDoes the glare from headlights or indoor lighting affect your vision or comfort?Have you ever experienced skin irritation caused by corrosion of your spectacle frame?Do you normally wear sunglasses?Are there times you would like to see clearly, but your glasses are inappropriate?Are you interested in Laser Vision Correction?