Patient Registration Form Step 1 of 4 25% Patient InformationFirst Name*Last Name*Gender*MaleFemalePrefer Not to AnswerMarital Status*SingleMarriedDivorcedWidowedOtherDate of Birth (Age)* Date Format: MM slash DD slash YYYY Social Security Number (xxx-xx-####)*Address* Street Address City ZIP Code Home Phone (###) ###-####*Mobile Phone (###) ###-####*Email* Enter Email Confirm Email Referred by*InsuranceYelpAngie's ListInternetFriend or FamilyOtherPrimary Care Physician Primary Care Physician PhonePharmacyCVSCostcoSam's ClubSmith'sWalgreensWalmartVonsOtherOther pharmacy please list here: Pharmacy Phone (xxx) xxx-xxxxPharmacy Address Street Address City ZIP Code Patient Employer/ School InformationEmployer/SchoolOccupation*Knowing your occupation helps us recommend the best lens products for your visual needs at work.Employer/School PhoneEmployer/School Address Street Address City ZIP Code Emergency Contact InformationEmergency Contact Name*Emergency Contact Phone*Relation to Patient*ParentRelativeFriendChildOther Billing and InsuranceAbout your Vision InsuranceVision Insurance Company*NoneAmerigroupAnthem Blue Cross & Blue ShieldBeech StreetBenefit PlannersCignaDavis VisionEyemedEyequestGolden RuleHumana VisionMedicaidMedical Eye ServicesMedicareNV Health Co-opOptum Health VisionSuperior VisionTricareVision Benefits of AmericaVSP (Vision Service Plan)OtherOther Vision Insurance List HereID NumberGroup NumberInsured’s Name*Relation to Patient*SelfParentSpouseChildInsured’s Phone NumberInsured’s Address (if same as patient write 'SAME') Street Address City ZIP Code Insured’s Social Security Number (xxx-xx-####)*Insured’s Birthdate* Date Format: MM slash DD slash YYYY Insured’s Employer/SchoolAbout your Health InsuranceHealth Insurance Company*Please list other insurance here:NoneAetnaAmerigroupAnthem Blue Cross & Blue ShieldBeech StreetBenefit PlannersClark County Self FundedCignaGEHAGolden RuleMedicaidMedicareNV Health Co-opTeamstersThe Loomis CompanyTricareUMROtherOther Health Insurance List HereInsured’s Name (if same as patient write "SAME")*Relation to PatientParentSpouseChildSelfInsured’s Address (if same as patient write 'SAME') Street Address City ZIP Code Insured’s Birthdate Date Format: MM slash DD slash YYYY ID NumberGroup NumberResponsible Party (Billing Name if other than patient or insured)PhoneRelation to PatientFather / MotherSon / daughterFriendRelativeOtherAddress Street Address City ZIP Code Visit InformationWho was your previous eye doctor?What brings you to the office today?*EyesHave you ever had eye surgery or laser eye treatments?*YesNoPlease list previous eye surgeries and dates here:Are you experiencing any following eye issues currently?*Please list other eye issues here:Amblyopia (eye not correctable to 20/20 'lazy eye')Blurred VisionDistorted Vision - HalosDouble VisionDryness in EyesEye PainEyelid InfectionEyes BurnEyes ItchEyes Sensitive to LightEyes Water / TearFlashes of LightsFloatersFluctuating VisionForeign Body Sensation in EyesLoss of VisionMucous in EyesPain in or around eyesRedness in EyesSandy Feeling in EyesStrabismus (eyes are not straight)StyeTired EyesOther (Please list below)NoneDo you wear glasses?*YesNoDo you wear contacts?*YesNoWhich brand?*Right Eye Power*Left Eye Power*When was your last eye exam? Date Format: MM slash DD slash YYYY Patient Medical HistoryHave you ever had any of the following health or eye conditions?*AIDS/HIVArthritisCancerDiabetesHeart DiseaseHigh CholesterolKidney DisorderLupusSjogren’s SyndromeStrokeThyroid DiseaseBlindnessCataractsCorneal DiseaseGlaucomaMacular DegenerationRetinal DisorderStrabismus (eye turn)NoneOtherIf 'other' please list here:AllergiesAre you allergic to any of the following? (Click all that apply)*Adhesive TapeBarbiturates (Sleeping Pills)CodeineAntibioticsAspirinSulfaLatexIodineLocal AnestheticsOtherNoneDo you have any other allergies?NameReactionOther Information Current MedicationsWhat medications are you currently taking? (if none please list "NONE")*NameDosageFrequency Family HistoryHas anyone in your family ever had any of the following conditions?*AIDS/HIVAmblyopia (Lazy Eye)ArthritisCancerDiabetesHeart DiseaseHigh CholesterolKidney DisorderLupusSjogren’s SyndromeStrokeThyroid DiseaseBlindnessCataractsCorneal DiseaseGlaucomaMacular DegenerationRetinal DisorderStrabismus (Eye Turn)OtherNoneIf 'other' please list here:Hospitalizations & SurgeriesReasonDateOther Info Lifestyle FactorsDo you drink?*NoSocially1-2 Drinks per dayAbove AverageAlcohol dependenceHave you ever smoked?*YesNo# of years# packs/dayDo you smoke now?*YesNoWhen did you quit smoking?# packs/dayDo you use recreational drugs?YesNoTypes?# times/weekDo you drive?YesNoDo you have difficulty driving?YesNoDo you have difficulty with night vision?*YesNo* I have read the Notice of Privacy Practice (HIPAA) PhoneThis field is for validation purposes and should be left unchanged. This form is not available for mobile devices. 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