Patient Registration--This is a secure page.

General Information

* Indicates a required response.  Failure to complete the required information will result in our office not receiving your form.
I have an appointment scheduled at: *
What is your Marital Status? *

Insurance Information

(If you do not have insurance for either health or vision, please type "None.")
        HEALTH INSURANCE INFO                        VISION INSURANCE INFO

Eyeglass History

Do you wear glasses? *
What type of glasses do you own? *
Do you use a computer? *
 *
 YesNo
If you wear eyeglasses, are there certain times when you would rather not?
If you wear eyeglasses, does your spare pair have your correct prescription?
Do your sunglasses have UV (ultra-violet) protection?
Are your sunglasses your current prescription?

Contact Lens History

 YesNo
Do you currently wear contact lenses?
Have you ever tried to wear contact lenses?
Are you interested in changing or enhancing your eye color?
If you currently wear contact lenses, do your backup eyeglasses have your correct prescription?
Are you having any problems with your current contacts?
Answer the questions below ONLY IF you currently wear contact lenses:
 Hours/DayDays/Week
What is your typical contacts wearing schedule?
 YesNo
Would you like to be evaluated for refractive laser surgery?

Medical History

Do you suffer from: *
 YesNo
Headaches?
Glare/Light Sensitivity?
Tired Eyes?
Amblyopia (lazy eye)?
Burning?
Dryness?
Epiphora (excess tearing)?
Eye Pain or Soreness?
Foreign Body Sensation?
Infection of Eye or Lid?
Itching?
Mucous Discharge?
Night Driving Difficulties?
 *
 YesNo
Ptosis (drooping eyelid)?
Redness?
Sandy or Gritty Feeling?
Strabismus (crossed eyes)?
Blurred Distance Vision?
Blurred Near Vision?
Distorted Vision (haloes)?
Double Vision?
Floaters or Spots?
Fluctuating Vision?
Loss of Vision?
Loss of Side Vision?
Many diseases of the body have grave eye health consequences.  While the questions below may seem unrelated to your eye health, it is crucial to your care that we ask them.
Have you ever been treated for any MEDICAL CONDITIONS?
   (e.g., diabetes, high blood pressure, arthritis) *
Have you ever had any EYE DISEASE?
   (e.g., glaucoma, cataracts, wandering or "lazy" eye, retinal detachment) *
Have you ever had any SURGERY for your eyes or any other condition? *
Do you take any MEDICATIONS? *
Do you have any food or drug ALLERGIES? *
Do you currently have any of the following: *
 YesNo
Chronic fever / unexpected weight loss or gain / fatigue?
Ear/Nose/Throat problems (e.g., hearing loss, sinus problems, sore throat?)
Heart problems (e.g., chest pain, irregular heartbeat, swelling of feet, cold hands/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 urine, 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 much of 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)?

Family/Social History

Do any MEDICAL or EYE DISEASES run
in your family (blood relatives only)? *
Do you consume alcohol? *
Do you smoke? *

Insurance Disclaimer

We will gladly assist you in filing insurance for which we are a provider but we cannot assume responsibility for your insurance policies.  Verification of benefits and authorizations received from your insurance company are not a guarantee of payment. The amount you will pay today is your estimated portion. 

 

I understand that Optique Vision Center will bill me for any items and/or services denied by my insurance company.  I understand that I am personally and financially responsible for these charges and hereby authorize the provider to release any information required to process my insurance claim.  I also authorize my insurance benefits to be paid directly to the doctor.

Notice of Privacy Practices

Click to view our Notice of Privacy Practices.
I acknowledge that I have had a chance to view and print out a copy of the Optique Vision Center Notice of Privacy Practices.

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If this is being completed for a minor, please list a name and phone # for an adult we may contact for further information.

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