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
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
- What is your reason for your visit?
- Are you interested in new eye glasses?
- Are you interested in new contacts?
- Are you a current contact wearer?
- Are you interested in sunglasses?
- Any hobbies or tasks your perform that you would like a different pair of glasses for? If yes, please describe.
- Have you ever had an eye injury or surgery?
- Please describe your eye injury or surgery:
- Do you currently take any EYE medications?
- What EYE medications are you currently taking?
- Dilation of the pupils allows the doctor to obtain a more thorough view of the retina. Our doctors like to do this on every diabetic or if they feel the need to have a better look of the back of the eye. The doctor would place a couple of drops in each eye that would increase your pupil size. The most common side effects include light sensitivity, decreased near vision and glare. It will take anywhere from 15-30 minutes for your pupils to dilate and the side effects will last anywhere from 2-4 hours. Any retinal problems that are not found should you choose not to be dilated, will not be the doctor's responsibility. The doctor will be happy to discuss dilation with you during your exam.
- I understand the importance of dilation and
- 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?
- Please list your medication(s) and dosage.
- Are you allergic to any medications?
- 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?
- Name of Vision Insurance:
- Member ID Number:
- Who is the policy holder for this insurance?
- 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?
- To comply with the new HIPAA Federal Privacy Regulations, we must receive your written approval to discuss your case with anyone else including family, children, caregivers, etc. By authorizing this, we will be able to, without requiring your presence, discuss your case, answer questions, and leave detailed messages and contact, in the cast of an emergency, the person listed below. If you would like us to answer questions or discuss your case with anyone other than yourself, you must include them below. This authorization is optional and can be withdrawn at any time by you.
- Name:
- Relationship to patient:
- Date of birth:
- Phone Number:
- Signature
- DateTime
- Which office did you make an appointment at?
- Have you scheduled the appointment yet? If not, please go back to the website to request your appointment.
- For all CURRENT and NEW patients:
  
  Please bring a photo ID, all insurance cards, and a list of medications to your appointment!
  
  Thank you!
- Please verify that you are human
- Should be Empty:

Online Registration Form