Name: Premier Eye Center Plantation
Address: 7045 West Broward Boulevard, Plantation, FL, 33317, US
Telephone: 954-625-2388
Price range: $000 - $300

New Patient Registration Form

Select Office*
Name*
First Last
Phone*
Email Address*
Address*
Street Address City ZIP / Postal Code
Patient's Date of Birth*
MM slash DD slash YYYY
Primary Medical Insurance*
Vision Insurance*
Last 4 SSN*
If the policyholder is also the patient, click here
- Yes
- No
Primary policy holder name
Primary policy holder DOB
MM slash DD slash YYYY
last 4 digits of your SSN
Member ID*
Today's Date
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:
- Asian
- Black/African-American
- Hispanic
- White
- Decline to respond
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)
I have reviewed and understand that the Premier Eye Center Privacy and patient Consent Policy is displayed in office, on our website, and I can ask for a copy (printing/electronic) of it at any time. I (patient or guardian) consent that all information I have submitted is accurate.
Signature
(Patient or Guardian)
Date
MM slash DD slash YYYY
To have your chart accessible to someone else on your behalf for medical, financial concerns, please put name(s) below:
Name
First Last
Number:
If no name is entered and the patient is over 18 years old despite insurance coverage we will need written consent by the patient.
MEDICAL HISTORY
Name of Family Physician:
Date of Last Physical Exam:
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:
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*
MM slash DD slash YYYY
Policy holder last 4 SSN*
Test 1: Optomap Retinal Screener
We at Premier Eye Center perform a state-of-the-art digital scanning technology as part of yout annual medical eye exam.

This allow our doctors to view the inside of your eye without the use of dilation drops, unless dilation is necessary. The OPTOMAP allows the doctor to evaluate your retina for problems such as diabetes, high blood pressure, retinal rips, tumors, bleeding, and several other medical eye conditions. The doctor is also better able to evaluate and monitor any changes by comparing the images from year to year.

This scanning system is safe for both kids, adults and during pregnancy.
- Test 1: The $49 copay is incorporated into today's copays (standard care).
It is strongly recommended that ALL patients have a thorough examination of their retina every year. Without the Optomap or a dilated examination, serious eye conditions can be missed. Dilation may still be required.
Test 2: Glaucoma and Visual Field Testing(optional)
We utilize the newest technology for glaucoma screeing the Humphrey FDT Matrix. This will detect any changes related to glaucoma or pathology existing behind the eye. The technology also give information regarding the visual pathway from the brain to the eyes. This helps in the management of headaches and/or migraines, and rules out potential consequences such as tumors or brain masses. If treatment is necessary, our doctors are able to treat and manage eyes disease-related to abnormal visual fields.
- I elect to have the FDT Matrix screener Original Price ~~$100.00~~ Now $39.00
- I decline addintional FDT Matrix screening
Signature
By signing I acknowledge any fee’s associated to my examination
Date
MM slash DD slash YYYY

Plantation 954-625-2388

Boca Raton 561-482-8300

West Palm 561-964-1359

New Patient Registration Form

New Patient Registration Form

Necessary Information Data

VERY IMPORTANT! NEW PATIENTS ONLY

MEDICAL HISTORY

Do you currently, or have you ever had any problems in the following areas?

EYE HEALTH HISTORY

FAMILY HISTORY

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