Using this electronic registration will not only save you considerable time on the day of your visit, it will increase the the accuracy and completeness of your file which will help us to arrive at a proper diagnosis. This information is confidential and will not be shared with anyone without your signed instructions to do so. If you have already filled out one of these on an earlier visit, please just fill in any changes or new problems that have arisen since your last visit, but be sure to put your name in the first box, since there is no other way we can identify who is sending this.

Patient name:     

Mailing address:

City, state, zip:    

Home phone:      

Other phones:    

e-mail address:  

Date of Birth:      

Occupation:        

Employer:           

Referred by:        (or how did you originally find us?)

The rest of this form asks specific questions about the patient's medical history. This information is VERY important in the diagnostic process and we hope you will be as candid and as complete with your responses as possible to insure the appropriate examination, diagnoses, and treatment.

List any allergies (including to medications, seasonal, etc.):

List any current medications being taken:

List any medical conditions:

List any family history of eye disease:

List any personal history of eye disease, eye surgery, or eye injury:

Describe any current eye or vision problems, or the main reason for the visit:

History of eyewear (include prescriptions for glasses and contacts if available):

If the patient is a minor (under age 18), name of responsible person:

When you hit the submit button, the form will be sent directly to Dr. Stacy.