richmondfamilyeyecare.com - Patient Registration Form

Patient Registration Form
Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information
Name*

PrefixFirst NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Daytime Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email Address
example@example.com
Personal Information
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Social Security Number (last 4 digits only!)
Preferred Language*
Race*
Ethnicity:*
Marital Status:
Employment Status*
Employer
Occupation
How were you referred to our office?
Communication Preference
Eye History
Please check off any current conditions you suffer from

I stopped wearing glassesI stopped wearing contact lensesHeadachesGlare/Light SensitivityTired EyesAmblyopia (lazy eye)BurningDrynessWatery EyesEye Pain and/or SorenessForeign Body SensationInfection of Eye or LidItchingMucous DischargeDrooping eyelid(s)RednessSandy or Gritty FeelingStrabismus (crossed eye)Blurred Vision at DistanceBlurred Vision at NearHaloesDouble VisionFloaters or SpotsFluctuating VisionLoss of VisionLoss of Side Vision
Glasses History
Do you wear glasses?*

YesNo
What glasses do you own?

Single VisionBifocalsSafety GlassesBackup GlassesProgressiveTrifocalsSports GlassesSunglasses
How many hours a day do you use a computer?
Please enter a number from 0 to 24.
How many inches away, approximately, do you sit from your computer monitor?
Please enter a number from 0 to 120.
Please check off any current conditions you suffer from

I am having problems with my current glassesThere are times when I would rather not be wearing glassesI have problems with glareI have problems with night visionI am allergic to nickel (e.g. frames of glasses)I don’t have spare set of glassesMy spare glasses have an incorrect prescriptionMy sunglasses are missing UV (ultra-violet) protection
Contact Lens History
Do you wear contact lenses?*

YesNo
What brand of contact lenses do you wear?
How old are your current lenses?
How often do you replace or dispose your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule? In hours per day:
Please enter a number from 0 to 24.
What is your typical wearing schedule? In days per week:
Please enter a number from 0 to 7.
Please check off all that apply to you

I am having problems with my current contact lensesThere are times when I would rather not be wearing contact lensesI am interested in changing or enhancing my eye colorI am interested in a non-surgical method of vision correctionI am interested in refractive laser surgeryI don't have a spare set of contact lensesMy spare contact lenses have an incorrect prescription
Medical History
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Do you drink alcohol?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any current conditions you suffer from

Chronic fever, unexpected weight loss/gain, fatigueEar/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)Respiratory problems (eg. Shortness of breath, wheezing, coughing)Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)Skin problems (eg. Rashes, excessive dryness, growths or lumps)Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)Psychiatric problems (eg. Depression, anxiety)Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)
Primary Insurance

Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Insured's Name

First NameLast Name
Identification Number
Group Number
Insured's Date of Birth

MonthDayYear
Date
Patient's Relation to Insured
Do you have secondary insurance?

YesNo
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Insured's Name

First NameLast Name
Identification Number
Group Number
Insured's Date of Birth

MonthDayYear
Date
Patient's Relation to Insured
Comments
If you have any comments you would like to add, please enter them here.
Should be Empty:

Patient Registration Form

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Comments