Free Eye Clinic Patient Registration Form Template

Eye Clinic Patient Registration Form

Please complete the required information in the fields below to complete your registration process.

Patient Information

Name

    Date of Birth

      Gender

        • Male

        • Female

        Address

          Phone number

            Email

              Emergency Contact

              Name

                Relationship to Patient

                  Phone number

                    Insurance Information

                    Insurance Provider

                      Policy Number

                        Group Number

                          Policyholder's Name

                            Medical History

                            Primary Physician

                              Do you have any allergies?

                              Current Medications

                                Do you have any of the following conditions?

                                  • Glaucoma

                                  • Cataracts

                                  • Macular Degeneration

                                  • Diabetic Retinopathy

                                  Vision and Eye Health History

                                  Do you wear glasses?

                                  Do you wear contact lenses?

                                  Reason for Visit

                                    Do you have any vision problems?

                                    Consent and Acknowledgment

                                    I, the undersigned, hereby consent to the examination and treatment by the staff of the Eye Clinic. I understand that my medical and insurance information will be kept confidential.

                                    Date:

                                    Registration Form Templates @ Template.net