Patient Registration Form

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?

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 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 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

Please check off any current conditions you suffer from *