Patient Registration - In Focus Eye Care

Are you a New or Existing patient at In Focus Eye Care?*

New
Existing

Name*

First Last

Phone*

Daytime Phone

Email

Communication Preference

Phone
Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal Information

Gender

Female
Male

Date of Birth*

Employment Status*

Employment Status - Other

Occupation

How were you referred to our office?

Referral - Other

Please let us know how you were referred to our office.

Name of person who referred you

Eye History

Please check any current conditions you suffer from*

I stopped wearing glasses because:

I stopped wearing contact lenses because:

Glasses History

Do you wear glasses?*

Yes
No

What glasses do you own?

Other glasses

How many hours a day do you use a computer?

Please enter a number from 0 to 24.

How many inches away, approximately, do you sit from your computer monitor?

Please enter a number from 0 to 120.

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
No

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:

Please enter a number from 0 to 24.

What is your typical wearing schedule? In days per week:

Please enter a number from 0 to 7.

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?*

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 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

Primary Insurance

Complete this section if your insurance plan has changed recently. Please bring insurance cards with you to your appointment.

Do you have an insurance plan?

Yes
No

Insurance Company Name

Identification Number

Group Number

Insured's Name

First Last

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

Complete this section if your insurance plan has changed recently. Please bring insurance cards with you to your appointment.

Do you have secondary insurance?

Yes
No

Insurance Company Name

Identification Number

Group Number

Insured's Name

First Last

Insured's Date of Birth

Patient's Relation to Insured

Comments

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