New Patient Online Registration

New Patient Registration

PATIENT INFORMATION

Name(Required)

Name as it appears on your insurance card.

First Middle Last

Date of Birth(Required)

Gender(Required)

Female

Male

Mobile Phone Number(Required)

We use mobile messaging as the fastest method for appointment reminders, order status, and live two-way communications. We will never message you promotional info.

Home Phone Number

Email Address

Address(Required)

Street Address City State ZIP Code

Employer

Occupation

How were you referred to our office?

MEDICAL HISTORY

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol?(Required)

Do you smoke?(Required)

Please list all major injuries and surgeries you have had and what year they occurred.

This includes eye surgeries such as LASIK and cataract surgery.

Do you have any of the following conditions? Please check all that apply.(Required)

Does your FAMILY have history of any of these conditions?(Required)

Please list any other major medical conditions that you may have:

Some examples are chronic fatigue, "blackouts" or neurological issues, irregular heart beat, shortness of breath, Crohn's disease, Shingles, frequent infections, depression, etc.

A Medical Eye Exam is recommended.

To address or treat any of the conditions you checked above at your visit the Doctors must perform a Medical Eye Exam. This exam will address your non-routine medical conditions and evaluate their impact on your vision. You will have the option to get a new prescription for glasses and/or contacts as well. Medical Eye Exams are billed to medical insurance, not vision insurance.

May we see you for a Medical Eye Exam?(Required)

Yes, I would like a medical eye exam

No, do not address my medical conditions, I would like a routine vision exam only

Would you like a prescription for glasses (refraction) at your visit?(Required)

Refraction is the determination of your vision prescription. Medical Eye Exams do not include refraction. You may have a refraction in addition to your medical exam for $49.

Yes ($49)

No (no prescription for glasses or contacts)

MEDICATION

Do you take any prescription medications?(Required)

Yes

Please list all prescription medications you take and dosage:(Required)

OR, upload a photo or scan of your medications

Max. file size: 31 MB.

Do you take regular over-the-counter medications?(Required)

Yes

Please list all over-the-counter medications you take and how often:(Required)

OR, upload a photo or scan of your medications

Max. file size: 31 MB.

Do you have any drug allergies?(Required)

Yes

Please list all drug allergies you have(Required)

VISION

When, approximately, was your last eye exam?(Required)

Please check any Vision sensations that apply:(Required)

Please list any other eye conditions or vision problems you would like to discuss.

OPTOMAP(Required)

Optomap is a digital scan of the interior of your eye which allows the doctor to assess your eye health. It is the recommended method by the doctors, and replaces traditional chemical dilation which opens the eye so the doctor can inspect visually. Dilation does impair vision for 6-8 hours. If dilation is preferred please ensure you bring sunglasses, and make arrangements to not drive or perform vision intensive tasks for 6-8 hours immediately following your exam.

Yes, I would like Optomap for $39

No, I prefer dilation

EYEGLASSES

Do you own glasses?(Required)

Yes

What eyeglasses do you own? Please select all that apply.

Please bring all glasses to your eye exam to discuss updating lenses for different uses.

CONTACT LENSES

Contact lens examinations are elective and additional to your vision exam. Fees vary from $60-$250. Insurance does not cover this expense, and fees are due the date of the exam.

Do you wear contact lenses?(Required)

Yes

If you do not wear contact lenses, would you like to be examined for them at your visit?

Yes, and I have not worn contacts before

Yes, and I HAVE worn contacts before but discontinued them

Would you like a contact lens exam to renew your prescription?

Contact lens exam are required annually to maintain a prescription. If you plan to continue contact lens wear you should elect the examination.

Yes

What kind of contacts do you wear?

Soft; Daily disposable

Soft; bi-weekly

Soft; monthly

Rigid

Other

What days do you wear contact lenses?

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

How many hours a day do you wear your contact lenses?

How often do you replace your contact lenses?

INSURANCE

If you would like us to bill any insurance we will need all accurate data regarding Primary and Vision Insurance.

Would you like us to bill any insurance? Check all that apply(Required)

Yes, medical insurance

Yes, vision insurance

Pay privately

Medical Insurance

Card Upload

In lieu of filling in the information below you may upload front and back images of your medical insurance card.

Drop files here or

Max. file size: 31 MB.

Medical/Primary Insurance

Member ID Number

Who is the Primary Insured Member?

First Last

Insured Member's Social Security Number

Vision Insurance

Card Upload

In lieu of filling in the information below you may upload front and back images of your vision insurance card.

Drop files here or

Max. file size: 31 MB.

Vision Plan

VSP

Eyemed

Spectera

Other

Who is primary on the vision plan?

Self

Other

Primary Member

First Last

Primary member's Date of Birth

Vision Insurance ID Number

Your primary medical insurance company can verify your Vision Insurance ID Number.

Insured Member's Social Security Number

If different from ID number.

Acknowledgment of Practice Policy(Required)

I agree to the Practice Policy.

See Family Vision Center Practice Policy here.

Comments

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