Online Registration
PATIENT NAME AND INFORMATION
Last Name:
First Name:
Middle Name:
Date of Birth:
Social Security (SSN):
Gender:
Male
Female
Other
Street Address
address continued
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip
Home Phone:
Work Phone:
Mobile Phone:
Email Address:
Date of scheduled appointment:
Location:
Please select...
Jupiter
Port St. Lucie
Wellington
West Palm Beach
Delray Beach
PARENT/INSURED INFORMATION
Insurance Provider
Group #
Member #
Front of Insurance Card
Take a picture or upload a picture of the front of your insurance card.
Back of Insurance Card
Take a picture or upload a picture of the back of your insurance card.
Last Name:
First Name:
Date of Birth:
Social Security (SSN):
Gender:
Male
Female
Other
Street Address
address continued
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip
Home Phone:
Work Phone:
Mobile Phone:
Email Address:
REFERRING PHYSICIAN/PRIMARY PROVIDER INFORMATION
Doctor/Provider Name:
Phone Number:
Fax Number:
Email/Website:
MORE INFORMATION
Main reason for today's visit:
Doctor(s) who should get reports:
Please separate using commas.
Phone Number:
Fax Number:
Do you want examination for glasses or lenses or a prescription for glasses or lenses as part of today's visit/exam?
YES
NO
Please note that there is a separate charge for refraction (glasses examination) that is not covered by medicare and by most insurance plans.
MORE INFORMATION
Your eye condition(s):
List any known eye conditions you may have, eye surgery you have had and when.
Do you take medication for your eyes?
YES
NO
Medication
1.
Frequency
Which Eye
Reason
Medication
2.
Frequency
Which Eye
Reason
Medication
3.
Frequency
Which Eye
Reason
MORE INFORMATION
Family History
Unknown
Known
Cataract
Yes
No
Glaucoma
Yes
No
Retinal Detachment
Yes
No
Blindness
Yes
No
Macular Degeneration
Yes
No
Diabetes
Yes
No
Retinitis Pigmentosa
Yes
No
Other familial ocular disorder
REVIEW OF SYSTEMS AND MEDICAL CONDITIONS
Do you have trouble with...
CANCER
Yes
No
EARS, NOSE, THROAT
Yes
No
HEART:
Chest pain
Yes
No
Irregular Heart Beat
Yes
No
High Blood Pressure
Yes
No
CIRCULATION:
Cold hands or feet
Yes
No
LUNGS AND BREATHING:
Wheezing or asthma
Yes
No
STOMACH OR INTESTINES
Yes
No
KIDNEY AND URINE:
Kidney stones in urine
Yes
No
Blood in urine
Yes
No
BONES, JOINTS, MUSCLES
Yes
No
SKIN
Yes
No
BREAST
Yes
No
NEUROLOGICAL PROBLEMS:
Stroke
Yes
No
Migraine Headaches
Yes
No
Non-Migraine Headaches
Yes
No
MENTAL OR EMOTIONAL:
Stress
Yes
No
Nervousness
Yes
No
Insomnia
Yes
No
GLANDS OR HORMONES:
Diabetes
Yes
No
Thyroid Problem
Yes
No
BLOOD:
Anemia
Yes
No
Past Blood Transfusions
Yes
No
ALLERGIES:
Bad reaction to medication
Yes
No
Sulfa allergy or bad reaction
Yes
No
Penicillin allergy or reaction
Yes
No
Food Allergies
Yes
No
Hay Fever
Yes
No
OTHER
FINAL STEP
Other medical conditions:
List past and present medical conditions, major illnesses and injuries, hospitalizations, surgery.
Do you take medication for these medical conditions?
YES
NO
Medication
1.
Frequency
Type
Reason
Medication
2.
Frequency
Type
Reason
Medication
3.
Frequency
Type
Reason
Medication
4.
Frequency
Type
Reason
Medication
5.
Frequency
Type
Reason