Online Patient Registration and Medical History
 
 
 
 

Patient Information

Advanced Directives - If you have a DNR, please bring a copy to your appointment or email it to [email protected]

Privacy Regulations - Due to privacy regulations, please indicate below anyone that you want to allow to inquire about your medical status.
*I authorize the following person(s) to communicate with your office regarding my care:

Emergency Contact

Employment Information

Referral Information

Healthcare Providers

Name of Insurance Company or Health Benefit Plan

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Medical History

Social History

Past Medical Surgery

Past Eye Surgery, Disease or Injury

Family Members Eye Medical History

Your Vision and Eye History

Prescription Medication Information Sheet

Eye Medication List

Preferred Pharmacy Refill Location

Drug Allergies

List of Other Physicians/Specialists involved in your care

Verification