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. In addition, please Click Here to print out our additional form and bring it to your appointment.

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.

Patient Information

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*

Social Security Number (last 4 digits only!)

Preferred Language*

Race*

Ethnicity*

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference


​​​​​​​Eye History

Please check off any current conditions you suffer from


​​​​​​​Glasses History

Do you wear glasses?*


​​​​​​​Contact Lens History


    ​​​​​​​Medical History

      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?

                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 list all drug allergies you have


                  ​​​​​​​Primary Insurance

                  Please bring all insurance cards with you to your appointment.

                  Insurance Company Name

                  Insurance Company Phone Number

                  Street Address

                  Address Line 2

                  City

                  State / Province / Region

                  ZIP / Postal Code

                  Country

                  Insured's Name

                  Identification Number

                  Group Number

                  Patient's Relation to Insured


                  ​​​​​​​Secondary Insurance

                  Do you have secondary insurance?

                  If you have any comments you would like to add, please enter them here.

                  12345 none 8:00 AM - 5:00 PM 9:00 AM - 7:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM By Appointment Only Closed optometrist # # # 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 9:00 AM - 7:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 8:00 AM - 12:00 PM Closed 4196783016 4196788849 201 S 2nd St Coldwater, OH 45828-1747 Coldwater Location 9:00 AM - 7:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM By Appointment Only Closed 4193945184 4193949941 250 Greenville Rd St Marys, OH 45885-2805 St. Marys Location