Patient Registration Form

Thanks for contacting us! We will get in touch with you shortly.

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.

Location *

Patient Information

Name *

First

Last

Street Address *

City

State

ZIP Code

Phone Number *

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

Daytime Phone

Cell Phone

Email Address *

Please provide us your email address.

Personal Information

Gender *

Female

Male

Date of Birth *

Social Security Number (last 4 digits only!)

Preferred Language *

Race *

Ethnicity *

Marital Status

Marital Status - Other

Please provide your marital status.

Employment Status

Employment Status - Other

Please provide your employment status.

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

Eye History

Please check off any current conditions you suffer from

I stopped wearing glasses

I stopped wearing contact lenses

Headaches

Glare/Light Sensitivity

Tired Eyes

Amblyopia (lazy eye)

Burning

Dryness

Watery Eyes

Eye Pain and/or Soreness

Foreign Body Sensation

Infection of Eye or Lid

Itching

Mucous Discharge

Drooping eyelid(s)

Redness

Sandy or Gritty Feeling

Strabismus (crossed eye)

Blurred Vision at Distance

Blurred Vision at Near

Haloes

Double Vision

Floaters or Spots

Fluctuating Vision

Loss of Vision

Loss of Side Vision

I stopped wearing glasses because:

I stopped wearing contact lenses because:

Glasses History

Do you wear glasses? *

Yes

What glasses do you own?

Single Vision

Bifocals

Safety Glasses

Backup Glasses

Progressive

Trifocals

Sports Glasses

Sunglasses

Other

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

I am having problems with my current glasses

There are times when I would rather not be wearing glasses

I have problems with glare

I have problems with night vision

I am allergic to nickel (e.g. frames of glasses)

I don't have spare set of glasses

My spare glasses have an incorrect prescription

My sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Do you wear contact lenses? *

Yes

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

I am having problems with my current contact lenses

There are times when I would rather not be wearing contact lenses

I am interested in changing or enhancing my eye color

I am interested in a non-surgical method of vision correction

I am interested in refractive laser surgery

I don't have a spare set of contact lenses

My spare contact lenses have an incorrect prescription

Medical History

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician?

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

Please list all drug allergies you have

Please check off any current conditions you suffer from

Chronic fever, unexpected weight loss/gain, fatigue

Ear/nose/throat problems

Heart problems

Respiratory problems

Gastrointestinal problems

Genitourinary problems

Musculoskeletal problems

Skin problems

Neurological problems

Psychiatric problems

Endocrine problems

Blood/Lymph problems

Immune problems

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insurance Company Phone Number

Street Address

City

State

ZIP Code

Insured's First Name

Insured's Last Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Yes

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

Insurance Company Name

Insurance Company Phone Number

Street Address

City

State

ZIP Code

Insured's First Name

Insured's Last Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Surgeries/Hospitalizations

Have you had any major surgeries and/or hospitalizations (including eye surgeries like cataract, LASIK, etc.)? *

Yes

If yes, please list:

Social History

This information is kept strictly confidential.

Occupational/Hobbies & special visual needs:

Do you use tobacco products? *

Yes

If yes, type/amount/how long?

Do you drink alcohol? *

Yes

If yes, type/amount/how long?

Do you use illegal drugs? *

Yes

If yes, type/amount/how long?

Are you currently pregnant? *

Yes

Ocular Health Evaluation

In order to examine the eye, we must dilate the pupil or take an Optomap image of the retina. Dilating drops enlarge the size of the pupil allowing the doctor a more thorough examination of your retina for eye diseases such as cataracts, glaucoma, retinal detachment, hypertension, diabetes etc. You may have blurry vision for 2-5 hours and light sensitivity. The Optomap camera allows a view without dilation in most cases for an additional charge.

Which method of ocular health evaluation do you prefer? *

Optomap (additional $40)

Dilation

Contact Examination

A contact lens evaluation is required for a contact lens prescription. This includes measurements of your eye, a trial pair of contacts (if available), and follow-up visits up to 6 weeks. This is a separate charge from the eye exam that ranges from $100-$200. VISION INSURANCE MAY NOT COVER THIS EVALUATION.

Are you taking any medications? Please list:

Are you allergic to any medications?

Comments

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Strong Vision Center

monday:: 9:00 am - 6:00 pm
tuesday:: 8:00 am - 7:00 pm
wednesday:: 9:00 am - 6:00 pm
thursday:: 9:00 am - 6:00 pm
friday:: 9:00 am - 6:00 pm
saturday:: Closed
sunday:: Closed

Strong Vision Center Fairfield

monday:: 9:00 am - 6:00 pm
tuesday:: 8:00 am - 7:00 pm
wednesday:: 9:00 am - 6:00 pm
thursday:: 9:00 am - 6:00 pm
friday:: 9:00 am - 6:00 pm
saturday:: Closed
sunday:: Closed