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Home » Returning Patient Registration Form

Returning Patient Registration Form

Today's Date
Date Format: MM slash DD slash YYYY
Name
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
last 4 digits of your SSN*
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance*
Member ID
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
Please list your employer:
Please list your occupation:
MEDICAL HISTORY
Name of Family Physician:
Date of Last Physical Exam:
Date Format: MM slash DD slash YYYY
Any NEW allergies to your medication list?
- 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.
EYE HEALTH HISTORY
The information in this confidential case history form is critical to the evaluation of your vision and health.
Do you have a backup pair of glasses?
- Yes
- No
Have you ever been diagnosed or treated for the following in the past year(s) since your last visit with us?
- 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
If there are no changes to your medical history, please check below.
- No changes
Is the patient also the insurance policyholder?
- Yes
- No
Primary policy holder name*
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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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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