Call us: 954-227-2770

Request Appointment

Home
Our Team
Eye Care Services
- Comprehensive Eye Exams
- Eye Conditions & Eye Disease Co-Management
Eyeglasses & Frames
Insurance

Home
Contact Us
Patient Registration Form

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.

"*" indicates required fields

Patient Information

Name*

Prefix First Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Please provide a telephone number, with area code, so we can contact you.

Daytime Phone

Cell Phone

Email Address

Please provide us your email address.

Personal Information

Gender*

Male

Female

Date of Birth*

MM slash DD slash YYYY

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

I stopped wearing glasses

I stopped wearing contact lenses

Headaches

Glare/Light Sensitivity

Tired Eyes

Amblyopia (lazy eye)

Burning

Dryness

Watery Eyes

Eye Pain and/or Soreness

Foreign Body Sensation

Infection of Eye or Lid

Itching

Mucous Discharge

Drooping eyelid(s)

Redness

Sandy or Gritty Feeling

Strabismus (crossed eye)

Blurred Vision at Distance

Blurred Vision at Near

Haloes

Double Vision

Floaters or Spots

Fluctuating Vision

Loss of Vision

Loss of Side Vision

I stopped wearing glasses because:

I stopped wearing contact lenses because:

Glasses History

Do you wear glasses?*

Yes

No

What glasses do you own?

Single Vision

Bifocals

Safety Glasses

Backup Glasses

Progressive

Trifocals

Sports Glasses

Sunglasses

Other

How many hours a day do you use a computer?

Please enter a number less than or equal to 24.

Please enter a number from 0 to 24.

How many inches away, approximately, do you sit from your computer monitor?

Please enter a number less than or equal to 120.

Please enter a number from 0 to 120.

Please check off any current conditions you suffer from

I am having problems with my current glasses

There are times when I would rather not be wearing glasses

I have problems with glare

I have problems with night vision

I am allergic to nickel (e.g. frames of glasses)

I don’t have spare set of glasses

My spare glasses have an incorrect prescription

My sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Do you wear contact lenses?*

Yes

No

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

Please enter a number from 0 to 24.

What is your typical wearing schedule? In days per week:

Please enter a number less than or equal to 7.

Please enter a number from 0 to 7.

Please check off all that apply to you

I am having problems with my current contact lenses

There are times when I would rather not be wearing contact lenses

I am interested in changing or enhancing my eye color

I am interested in a non-surgical method of vision correction

I am interested in refractive laser surgery

I don't have a spare set of contact lenses

My spare contact lenses have an incorrect prescription

Medical History

When, approximately, was your last eye exam?

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?

Do you smoke?

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 check off any current conditions you suffer from

Chronic fever, unexpected weight loss/gain, fatigue

Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)

Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)

Respiratory problems (eg. Shortness of breath, wheezing, coughing)

Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)

Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)

Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)

Skin problems (eg. Rashes, excessive dryness, growths or lumps)

Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)

Psychiatric problems (eg. Depression, anxiety)

Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)

Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)

Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)

Primary Insurance

Insurance Company Name

Please bring all insurance cards with you to your appointment.

Insurance Company Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

MM slash DD slash YYYY

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Yes

No

Insurance Company Name

Insurance Company Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

MM slash DD slash YYYY

Patient's Relation to Insured

Comments

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

Privacy Policy

Health Information Protection

I have read and agree to the Privacy Policy

Request An Appointment

Menu

Home
Disclaimer
Privacy Policy
News

Modern Optical FL

5976 Coral Ridge Drive
Coral Springs, FL 33076

Phone: (954) 227-2770
https://www.visionunlimitedoptical.com

Search the site

Accessibility
Sitemap
Privacy Policy
Disclaimer
Login

Copyright ©2024 Modern Optical FL | All rights reserved.