New Patient Registration
Susan Longar, M.D., Ting Ting Liu, M.D., Daniel Buckley, M.D., and Peter Martindale, O.D.
Name
*
First Name
Middle Name
Last Name
Gender
*
Please Select
Male
Female
Other
Race or Ethnicity
*
Primary Language
*
Age
*
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primacy Care Doctor
*
First Name
Last Name
Primary Care Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer
*
Occupation
*
Have you been referred by your Primary Care Doctor or another doctor?
*
Yes
No
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Vision Plan Insurance
Company
Name of Subscriber
First Name
Last Name
Relationship to Subscriber
Self
Spouse
Parent
Other
Vision Plan (VSP or MES)
Member ID
Last four numbers of SSN
Medical Insurance
Company
Name of Subscriber
First Name
Last Name
Relationship to Subscriber
Self
Spouse
Parent
Other
Member ID
Group Name (HMO)
Last four numbers of SSN
By signing below, I authorize my insurance benefits to be paid directly to the doctor and agree that I will be responsible for any non-covered services. I authorize my physician(s) and/or their agents to release any information to my insurance company to process claims for my care.
*
DateTime
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General Health
Please check all that apply.
*
Diabetes
Heart attack
Pregnant
Stroke
Lung disease
High blood pressure
Arthritis
Thyroid disease
Angina
Neurological problems
High cholesterol
HIV
Bleeding problems
Sinus problems
Injury (body or eye)
Cancer
Asthma
TB (active or not active)
None of these
Other
Eye Health
Eye Health
*
Cataract
Eye trauma
Eye surgery
Retinal detachment
LASIK/PRK
Macular degeneration
Diabetic retinopathy
Glaucoma
None of these
Other
Family Health
Has anyone in your family been diagnosed with the following?
*
Cataract
Glaucoma
Strabismus
Retinal detachment
Macular degeneration
Diabetic retinopathy
N/A
Other
Risk Factors
Do you...
*
Smoke
Drink
Work with machinery
N/A
Other
Medications
List of Medications / Eye Medications: please list meds you are currently taking, or attach a copy. If you are currently taking Flomax, please mention this to the Medical Assistant and your Doctor.
*
Allergy to Medications and Reactions
*
Submit
Submit
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