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Patient Registration Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Thanks for contacting us! We will get in touch with you shortly.

Patient Information

Name *
Address *
*
Please provide a telephone number, with area code, so we can contact you.
Please provide us your email address.

Personal Information

Gender *
Date of Birth *
*
*
*
Please provide your marital status.
Please provide your employment status.
Please let us know how you were referred to our office.

Eye History

Please check off any current conditions you suffer from

Glasses History

Do you wear glasses? *
What glasses do you own?
Please tell us what other kinds of glasses you own.
Enter a number between 0 and 24.
Please check off any current conditions you suffer from

Contact Lens History

Do you wear contact lenses? *
Please check off all that apply to you

Medical History

Please check off any current conditions you suffer from

Primary Insurance

Please bring all insurance cards with you to your appointment.
Insurance Address
Insured's Name
Insured's Date of Birth

Secondary Insurance

Do you have secondary insurance?
If you have coverage through another plan/organization, please fill in the details below.
Address
Insured's Name
Insured's Date of Birth

Fundus Retina Photo

Would you like a Retina Fundus Photo taken today? Dr. Wike feels like it is very important for baseline photographs to be taken of your retina, so that we may document changes over time. Insurance does not cover this routine test, unless Dr. Wike finds that insurance deems it a necessary test. The cost for this important test is $35. *

Patient Acknowledgement

I authorize Optometric Eye Clinic to release information concerning treatment:
Authorized Recipient Name 1
Authorized Recipient Name 2
Authorized Recipient Name 3

Comments

Privacy Policy

Health Information Protection *
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Date signed *