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*

Prefix First Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Please provide a telephone number, with area code, so we can contact you.

Consent*

I consent to receive text messages and communications from Eyexam Associates, PA.

Daytime Phone

Cell Phone

Email Address

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Personal Information

Gender*

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Date of Birth*

Social Security Number (last 4 digits only!)

Please enter a number from 0000 to 9999.

Preferred Language*

Race*

Ethnicity*

Marital Status

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Employment Status

Employment Status - Other

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Employer

Occupation

How were you referred to our office?

Referral Status - Other

Please let us know how you were referred to our office.

Communication Preference

Medical History

When, approximately, was your last eye exam?

Who is your primary care physician?

Do you drink alcohol?

Do you smoke?

For what conditions do you see a physician?

What medications do you take?

Please list all drug allergies you have:

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Primary Medical Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Vision Care Insurance

If you have coverage through another plan/organization, please fill in the details below.

Insurance Company Name

Insurance Company Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

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Patient Registration Form