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Patient Registration
General Information
First Name
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Last Name:
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M.I.
Salutation:
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Dr.
Mr.
Mrs.
Ms.
Other
Sex:
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Male
Female
Street or P.O. Address:
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City:
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State:
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip:
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Date of Birth:
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Age:
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Home Phone #:
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Soc. Sec. #:
Cell Phone #:
Email Address:
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Employer:
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Occupation:
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What is the major purpose of this visit?
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Any problems with your current contact lenses or glasses?
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0/255 characters
How did you hear about us?
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Family Member
Friend
Another Doctor
Insurance Company
Internet Search
Yellow Pages
Newspaper
Other
If you were referred by a physician or another individual, would you like to tell us who it was?
Insurance Information
PRIMARY INSURANCE INFO SECONDARY INSURANCE INFO
Insurance Company Name:
Insurance Company Name:
Employer:
Employer:
Group Number:
Group Number:
Policy Number:
Policy Number:
Name of Policy Holder:
Name of Policy Holder:
Insured's Date of Birth:
Insured's Date of Birth:
Insured's Social Security #:
Insured's Social Security #:
Patient's Relationship to Insured:
Patient's Relationship to Insured:
Medical History Questionnaire
Do you have any allergies to medications?
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No
Yes
If yes, please explain.
List any medications you take (including oral contraceptives, aspirin, over-the-counter medications, and home remedies:
List any of the following you have had: crossed eyes, lazy eye, glaucoma, retinal disease, cataracts, eye infections, eye injury, or eye surgery.
Are you pregnant or nursing?
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No
Yes