Eye Clinic Patient Registration Form
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
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Male
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Female
Address
Phone number
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?
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Glaucoma
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Cataracts
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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:
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