Norman & Miller Eyecare Registration Form

Online Registration Form

Please fill in the form below with the patient's information.
Full Name*

PrefixFirst NameLast Name
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Social Security Number
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
E-mail

Health History
Please list your primary care physician:
Please check all conditions for which the patient is currently being treated, or take medications for:
Constitutional:*
Neuro:*
GI:*
Hem/Lymph:*
GU:*
ENT:*
Endo:*
Cardio:*
Integ:*
Psych:*
Respiratory:*
Musc/Skel:*
Allergy/Imm:*
Has the patient ever been diagnosed with:*
Are you currently taking any medications?*

YesNo
Please list your medication(s) and dosage.
Are you allergic to any medications?*

YesNo
Please list any medication(s) you are allergic to.
Please indicate which immediate family member suffers from Cancer:*
Please indicate which immediate family member suffers from High Blood Pressure*
Please indicate which immediate family member suffers from Type 1 OR Type 2 Diabetes*
Please indicate which immediate family member suffers from Thyroid Problems*
Please indicate which immediate family member suffers from Cataracts*
Please indicate which immediate family member suffers from Glaucoma*
Please indicate which immediate family member suffers from Macular Degeneration*
Do you have vision insurance?*

YesNo
Name of Vision Insurance:*
Member ID Number:*
Who is the policy holder for this insurance?*

MyselfMy SpouseOther
What is the policy holder's name?*

First NameLast Name
What is the policy holder's birthdate?*

MonthDayYear
Date
What are the last 4 digits of the policy holder's Social Security Number?*

Online Registration Form