NEW PATIENT REGISTRATION (In order to provide you the best possible care, please complete this form and bring it to your first appointment. All information is strictly CONFIDENTIAL.) Contact Information First Name Last Name Daytime Phone Mobile Phone Email Street Address Suite/Apt. City State Zip Guardian Information (if patient is under 18 years of age) First Name Last Name Daytime Phone Mobile Phone Email Street Address Suite/Apt. City State Zip Patient Information Gender Date of Birth Social Security No Primary Insurance Information Provider Name Provider Phone Policy/I.D. No Group No Secondary Insurance Information Provider Name Provider Phone Policy/I.D. No Group No Additional Insurance Information Provider Name Provider Phone Policy/I.D. No Group No Financial Assignment Information I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable. Acknowledgment of Notice of Privacy Practices (NPP) Yes, I have read or had explained to me by this office the NPP & I wish to continue my care under said terms.No, I have not read this office's NPP but I was given the opportunity to read it and declined. I wish to continue my care under said terms.The NPP could not be read due to the emergent nature of the care needed. Signature agreeing to all above terms Date Patient History Vision Correction History (please check any that apply) Amblyopia (lazy eye)Blurred vision at a distanceBlurred vision at nearBurningDouble visionDrooping eyelid(s)Dryness Eye pain and/or sorenessFloaters or spotsFluctuating visionForeign body sensationHalosI experience regular headachesI stopped wearing contact lenses I stopped wearing glassesInfection of eye or lidItchingLoss of peripheral visionLoss of visionMucous dischargeRedness Sandy or gritty feelingSensitivity to light/glareStrabismus (crossed eye)Tired eyesWatery eyes Glasses History (check all that apply) What glasses do you own? Backup pairBifocalsDistanceProgressive lensReading Safety glassesSingle visionSports glassesSunglassesTrifocals What glasses do you own? Allergic to nickel (frames)I do not want to wear glassesIncorrect prescriptionNeed spare glasses Need sunglasses with UVProblems with current glassesProblems with glareProblems with night vision Other: How many hours per day do you spend using a computer? Contact Lens History (check all that apply) What brand of contacts do you wear? How old are your current contacts? How often do you replace them? What solution do you use for soaking? What is your typical wearing schedule? Check any that apply I do not want to wear contactsIncorrect prescriptionInterested in non-surgical correctionInterested in refractive laser surgeryNeed spare contactsProblems with current contactsWould like to change my eye color Family History (check all that apply) BlindnessDiabetes Eye turn/lazy eyeGlaucoma HypertensionMacular degeneration Allergies(please list) None General Medical History (please answer appropriately) When (approx.) was your last eye exam? Primary care physician name Primary care physician phone Please list all eye conditions you have experienced: Do you have any of the following? ArthritisAsthmaCancerDiabetesHeart disease High cholesterolHIVHypertension (high blood pressure)Migraines/headachesMultiple sclerosis (MS) Surgries: Other: Referral Information Why did you visit us? Keep in touch Referred by your doctorVisited our website Found us on social mediaReferred directly Facebook email @Twitter handle Questions and notes Do you have a question? Concern? We want to know.