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Hours & Locations
Informacion En Español

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About Us
Insurance
Eye Care Services
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Informacion En Español

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Hours & Locations
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Home » Contact Us » New Patient Registration Form

New Patient Registration Form

New Patient Registration Form

Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Phone*
Address*
Street Address City
Insurance*
last 4 digits of your SSN*
Member ID*
Today's Date
Date Format: MM slash DD slash YYYY
Please present BOTH Medical and Vision information NOW in order to insure that all benefits are applied appropriately to the fees today.
Necessary Information Data
Please check all that apply
Marital Status:
- Single
- Married
- Divorced
- Widowed
Employment Status:
- Unemployed
- Employed Full Time
- Employed Part Time
- Student
- Retired
- Self-Employed
Ethnicity:
(Required by the State of Florida)
- Asian
- Black/African-American
- Hispanic
- White
Please list your employer:
Please list your occupation:
VERY IMPORTANT! NEW PATIENTS ONLY
Who may we thank for referring you to our office?
If not referred, how did you choose our office for your needs?
Another Doctor
Signage/Location
Insurance List
Newspaper
Flyer
Yellow pages
Web pages
(search engine)
MEDICAL HISTORY
Name of Family Physician:
Date of Last Physical Exam:
Date Format: MM slash DD slash YYYY
Do you have any allergies to medications?
- Yes
- No
If yes, please explain:
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):
Height:
feet inches
Weight:
lbs.
Are you currently pregnant or nursing?
- Yes
- No
Do you use tobacco products?
- Yes
- No
If yes:
Type Amount How long
Do you drink alcohol?
- Yes
- No
If yes:
Type Amount How long
Do you use recreational drugs?
- Yes
- No
If yes:
Type Amount How long
List major injuries, surgeries, and/or hospitalizations you have had
Do you currently, or have you ever had any problems in the following areas?
Constitutional
Fever, weight loss/gain
- Yes
- No
Integumentary (skin)
- Yes
- No
Neurological
Headaches/Migraines
- Yes
- No
Stroke / Seizures
- Yes
- No
Endocrine
Thyroid/Other/Glands
- Yes
- No
Ear, Nose, Mouth, Throat
Allergies/Sinus
- Yes
- No
Chronic Cough
- Yes
- No
Dry Throat/Mouth
- Yes
- No
Respiratory
Asthma
- Yes
- No
Chronic Bronchitis/Emphysema
- Yes
- No
Vascular/Cardiovascular
Diabetes
- Yes
- No
Heart Pain
- Yes
- No
High Blood pressure
- Yes
- No
Vascular Disease
- Yes
- No
Gastrointestinal
Crohnʼs Disease
- Yes
- No
Acid reflux/IBS
- Yes
- No
Genitourinary
Genitals/Kidney/Bladder
- Yes
- No
Bones/Joints/Muscles
Rheumatoid Arthritis
- Yes
- No
Muscle pain / Joint pain
- Yes
- No
Lymphatic/Hematologic
Anemia / Bleeding Problems
- Yes
- No
Allergic/Immunologic
- Yes
- No
Psychiatric
- Yes
- No
EYE HEALTH HISTORY
The information in this confidential case history form is critical to the evaluation of your vision and health.
Date of last eye exam:
Date Format: MM slash DD slash YYYY
By Whom:
Do you wear glasses?
- Yes
- No
Have you ever tried contact lenses?
- Yes
- No
Do you currently wear contact lenses?
- Yes
- No
What kind?
Solution used?
If you wear contact lenses, are you satisfied with the vision and comfort?
- Yes
- No
Do you have a backup pair of glasses?
- Yes
- No
Have you ever been diagnosed or treated for the following?
- Cataracts
- Iritis/Uveitis
- Corneal Abrasion
- Lazy Eye
- Eye Infection
- Macular Degeneration
- Eye Injury
- Retinal Detachment
- Glaucoma
- Other Eye Disorders
Do you experience or have you ever experienced:
MEDICAL CONCERN:
- Flash of light
- Headaches
- Burning
- Redness
- Itchiness
- Watering
- Tearing
- Grittiness
- Glare
- Soreness
- Distorted vision
- Eye turn
- Crossed eyes
- Tired eyes
- Loss of vision
- Eye pain
- Occasional dryness
- Light sensitivity
- Mucous discharge
- Loss of side vision
- Sties or Chalazion
- Foreign body sensation
- Floaters/small spots
- Chronic infection of the eye and/or lid
VISION CONCERN:
- Blurry vision
- Double vision
- Night driving
- Halos
Is there anything specific that you want to address today?
Such as:
- Lasik
- Contact Lenses
- Blue light lens technology
- Sports goggles
- Transitions
- UV protection
- Other
If other, please specify:
FAMILY HISTORY
Blindness
- Yes
- No
Relationship
Cataracts
- Yes
- No
Relationship
Corneal Problems
- Yes
- No
Relationship
Crossed eyes/Lazy eyes
- Yes
- No
Relationship
Glaucoma
- Yes
- No
Relationship
Macular Degeneration
- Yes
- No
Relationship
Retinal Detachment
- Yes
- No
Relationship
Arthritis
- Yes
- No
Relationship
Cancer
- Yes
- No
Relationship
Diabetes
- Yes
- No
Relationship
Heart Disease
- Yes
- No
Relationship
High Blood Pressure
- Yes
- No
Relationship
Kidney Disease
- Yes
- No
Relationship
Lupus
- Yes
- No
Relationship
Thyroid Disease
- Yes
- No
Relationship
If you answered YES to any of the above or have a Condition not listed, please explain & list medications:
Is the the patient the insurance policyholder?
- Yes
- No
Primary policy holder name*
First Last
Primary policy holder DOB*
Date Format: MM slash DD slash YYYY
Policy holder last 4 SSN*

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Premier Eye Center of Boca Raton

7840 Glades Road, Suite 245
Boca Raton, FL 33434

Boca Raton

Premier Eye Center of West Palm Beach

3650 Forest Hill Boulevard, Suite 2
West Palm Beach, FL 33406

West Palm Beach

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Disclaimer

Home
Contact Us
Our Blog
Privacy Policy
Disclaimer

About Us
Insurance
Eye Care Services
Eyeglasses & Contacts
Hours & Locations
Informacion En Español

About Us
Insurance
Eye Care Services
Eyeglasses & Contacts
Hours & Locations
Informacion En Español

Premier Eye Center - Located at 7045 West Broward Boulevard, Plantation, Florida, 33317. Phone: 954-625-2388. https://www.premiereyedoctor.com/

Premier Eye Center - Located at 7840 Glades Road, Suite 245, Boca Raton, Florida, 33434. Phone: 561-482-8300. https://www.premiereyedoctor.com/

Premier Eye Center - Located at 3650 Forest Hill Boulevard, Suite 2, West Palm Beach, Florida, 33406. Phone: 561-964-1359. https://www.premiereyedoctor.com/

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