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Patient Registration Form

Patient Information and Medical History

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  • Family Medical History

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  • Patient's Medical History

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  • *Please be prepared with a list of the medications you take, along with the dosage and directions. *Please bring all the eyeglasses you currently use to your appointment. Including computer glasses and corrective sunglasses. *If you are a contact lens wearer, please come in wearing your contacts. *Please be prepared for you eyes to be dilated during your visit. This will affect your near vision for a few hours after your visit and your eyes will be very sensitive to light. We will give you a pair of disposable sunglasses before you leave, but you may wish to bring your own pair. If you are uncomfortable driving after dilation, please make arrangements for someone to drive you.
  • Please make sure you receive a message that says "Thank You" after you submit your form. If you do not receive this message, you have left a mandatory field blank and we will not be able to receive your paperwork.