Patient Registration Form

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. Note that fields with an asterisk (*) are required. You must click submit at the end of the form for your form to be properly completed.

This form contains confidential information and is delivered to your doctor through a secure Internet connection

Patient Information

Name *

Address *

Phone Number *

Email Address *

Personal Information

Gender *

Date of Birth *

Last 4 digits of Social Security Number *

Preferred Language *

Race *

Ethnicity *

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference

Eye History

Please check off any current conditions you suffer from

Glasses History

Do you wear glasses? * (If Yes, Please indicate the fields below)

What glasses do you own?

Other glasses:

How many hours a day do you use a computer?

How many inches away, approximately, do you sit from your computer monitor?

Please check off any current conditions you suffer from

Contact Lens History

Do you wear contact lenses? * (If Yes, Please indicate the fields below)

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

What is your typical wearing schedule? In days per week:

Please check off all that apply to you

Medical History

When, approximately, was your last eye exam? *

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol? *

Do you smoke? *

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

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

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list all hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions *
If no medications taken, write "none"

Please list all drug allergies you have * If no allergies to medications, write "none"

Please check off any current conditions you suffer from *

Primary Insurance

Please bring all insurance cards with you to your appointment.

Will you be using insurance? *

Insurance Company Name *

Insurance Company Phone Number

Insured's Name *

Identification Number *

Group Number

Insured's Date of Birth *

Patient's Relation to Insured

Secondary Insurance

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

Do you have secondary insurance?

Insurance Company Name *

Insurance Company Phone Number

Insured's Name *

Identification Number *

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Comments

If you have any comments you would like to add, please enter them here.

Los Alamitos Optometry Office Policies

Please read the following policies. By checking the box next to each statement you are acknowledging that you have reviewed and agree to each policy.

I have read and agree to the HIPAA Privacy Policy
I have read and agree to the Insurance Policy
I have read and agree to the Financial Responsibility Policy and I am aware that an appointment no-show or cancellation with less than 24 hours notice can result in a $50.00 fee.
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