New Patient Registration PATIENT INFORMATIONName(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 NumberEmail Address Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Employer Occupation How were you referred to our office?Friend or FamilyFamily DoctorOphthalmologistInsurance CompanyInternet SearchReceived MailingOtherMEDICAL HISTORYWhen, approximately, was your last physical exam? Who is your primary care physician? Do you drink alcohol?(Required)NoYes, 1 per weekYes, 1 per dayYes, 2 or 3 per dayYes, 4 or more per dayDo you smoke?(Required)NoYes, tobacco. Under 1 pack per day.Yes, tobacco. 1 pack per day.Yes, tobacco. More than 1 pack per day.Yes, marijuana or other.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) Any Cancer Cardiac Disease High Blood Pressure Diabetes Rheumatoid arthritis Multiple Sclerosis Glaucoma (or suspect) Color blindness Cataracts Macular Degeneration Amblyopia (lazy eye) Retinal Detachments Strabismus (cross eye) NONE Does your FAMILY have history of any of these conditions?(Required) Any Cancer Cardiac Disease High Blood Pressure Diabetes Rheumatoid arthritis Multiple Sclerosis Color blindness Glaucoma (or suspect) Cataracts Macular Degeneration Amblyopia (lazy eye) Retinal Detachments Strabismus (cross eye) NONE 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) MEDICATIONDo you take any prescription medications?(Required) Yes No Please list all prescription medications you take and dosage:(Required)OR, upload a photo or scan of your medicationsMax. file size: 31 MB.Do you take regular over-the-counter medications?(Required) Yes No Please list all over-the-counter medications you take and how often:(Required)OR, upload a photo or scan of your medicationsMax. file size: 31 MB.Do you have any drug allergies?(Required) Yes No Please list all drug allergies you have(Required)VISIONWhen, approximately, was your last eye exam?(Required) Please check any Vision sensations that apply:(Required) Blurred Vision at Distance Blurred Vision at Near Double Vision Light Sensitivity Tired Eyes Watery Eyes Floaters or Spots Fluctuating Vision Loss of Vision Loss of Side Vision None 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 $49 No, I prefer dilation EYEGLASSESDo you own glasses?(Required) Yes No 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. Single Vision full-time wear Progressive no-line multifocal Lined bifocal or trifocal Single Vision distance only (take off to read) Single Vision reading only (take off to see distance) Computer glasses Sunglasses Backup/spare glasses Sports or other hobby glasses Over-the-counter non-prescription reading glasses CONTACT LENSESContact 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 No If you do not wear contact lenses, would you like to be examined for them at your visit? No 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 No 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 Select AllHow many hours a day do you wear your contact lenses?How often do you replace your contact lenses? INSURANCEIf 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 InsuranceCard UploadIn lieu of filling in the information below you may upload front and back images of your medical insurance card. Drop files here or Select files 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 InsuranceCard UploadIn lieu of filling in the information below you may upload front and back images of your vision insurance card. Drop files here or Select files 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 NumberYour primary medical insurance company can verify your Vision Insurance ID Number. Insured Member's Social Security NumberIf different from ID number. Acknowledgment of Practice Policy(Required) I agree to the Practice Policy.See Family Vision Center Practice Policy here.CommentsThis field is for validation purposes and should be left unchanged.