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SOCIAL EYES
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Home
About
Request an Appointment
Services
Exams & Treatments
Myopia Control Therapy
Eyewear Collections
Location & Hours
Contact Us
SOCIAL EYES
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SCHEDULE YOUR EXAM
Patient Registration Form
P A T I E N T I N F O R M A T I O N
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Name
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Age
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P R I M A R Y I N S U R A N C E
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Member’s Name
Type of Vision Insurance:
Member’s ID# or SSN:
Member’s Birthdate:
Patient Relationship to Insured
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I understand that I am financially responsible for all fees for services provided and authorize payment of my medical benefits to IMAGINE Optometry for services rendered. If additional services are required (i.e. contact lens service, medical eye
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Signature:
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Relationship
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P H O N E N U M B E R S
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E Y E C A R E H I S T O R Y
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Date of Last Eye Exam:
Do you wear Glasses?
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Yes
No
Do you wear Contact Lenses?
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Yes
No
If yes, how old are your Glasses?
If yes, how old is your current pair?
Do you plan to get new Glasses today?
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If no, are you interested in Contact Lenses?
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Have you had Laser Refractive Surgery?
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Do you experience symptoms of Dry Eye?
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Yes
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If no, are you interested in Refractive Surgery?
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Office use only - SPEED Score
O C U L A R H E A L T H & R E V I E W O F S Y S T E M S
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Date of Last Physical Exam:
Type of Health Insurance
Do you currently, or have ever had any problems in the following areas? Mark Ye s, No or Family. Marking Family would indicate you have a parent or sibling that currently has the listed condition
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Glaucoma
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Yes
No
Family
Macular Degeneration
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Yes
No
Family
Retinal Disease
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Yes
No
Family
Strabismus
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Yes
No
Family
Amblyopia (lazy eye)
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Family
Eye Injury
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Family
Dry Eyes
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Injury
Double Vision
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Flashes / Floaters
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Eye Itch/Burn
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Eye Surgery
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If you answered Ye s or Family to any of the above or have any other conditions not listed, please provide some additional details below:
Do you use tobacco products?
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Do you consume 2 or morealcoholic beverages per day?
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Allergy / Immune (hay fever, immune deficiency)
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Cardiovascular / Vascular(heart disease, high cholesterol / blood pressure)
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Constitution (general illness / cancer)
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Ear, Nose, Throat(sinus congestion, sore throat)
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Endocrine (diabetes, thyroid, hormone dysfunction)
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Gastrointestinal (chronic diarrhea, ulcers)
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Genitourinary (kidney / bladder)
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Hematologic / Lymphatic(anemia, bleeding problems)
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Integumentary (rosacea, eczema)
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Musculoskeletal (arthritis, back pain)
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Neurological (headaches, migraines, seizures)
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Psychiatric (depression, anxiety)
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Respiratory (asthma, emphysema, chronic bronchitis)
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Women
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Are you pregnant?
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Due Date
Are you nursing?
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A L L E R G I E S
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No Known Drug Allergies
Latex
Seasonal Allergies
Aspirin
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Other
Medications
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List anymedications you are currently taking and the corresponding health condition:
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
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In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose information in order to treat you, to obtain payment for our services, and to conduct healthca
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I acknowledge that I have received IMAGINE Optometry’s Notice of Privacy Practices.
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Signature:
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