Online Registration Form

General Information

First Name*

Last Name*

Preferred Name

Address*

Address Line 2

City*

State*

Mobile / Cell Phone*

Primary Phone

Work Phone

Email*

Preferred Contact Method*

Patient Social Security Number

Gender*

Date of Birth*

For Minors: Father's Name

For Minors: Mother's Name

Minor lives with:

Marital Status

Race*

Ethnicity*

Insurance*

Insurance Information

Vision Insurance Provider*

Vision Insurance Subscriber Name*

Member ID# or SSN*

Subscriber's Date of Birth*

Primary Medical Insurance Provider*

Medical Insurance Subscriber Name*

Medical Insurance ID#*

Medical Insurance Policy# / Group ID#

Medical Insurance Subscriber Member Date of Birth*

Relation to Medical Insurance Subscriber*

How did you hear about our office?*

Do you participate in a Flex Spending Account?*

How will you be settling your account today?*

Exam History

Last Eye Exam
When was your last eye exam?
Who carried out last eye exam?
Currently Wear Glasses?*
Currently Wear Contacts?*
Any problems with current glasses/contacts? *
Reason for your visit?*

Optical & Medical HIstory

Have you experienced, or been treated for any of the following? Check all that apply.
Eye Conditions & Disorders*
Have you or an immediate family member experienced, or been treated for any of the following?
Medical History*
Have you experienced or been treated for any of the following?
If you checked any of the boxes above please explain below
Vision Symptoms*
Are you currently experiencing, or have you experienced any of the following?
Family HIstory*
Has any of your family members experienced, or been treated for, any of the following? Check all that apply
If you checked any of the boxes above please explain below

Medications & Vitals

Height
Weight
Current Medications*
Medication Drug Allergies*
Are you pregnant or nursing?*
Do you smoke?*
Have you ever smoked?*

Are you diabetic? If so, when were you diagnosed?*
Last A1C & Date
Diabetic Doctor's Name/Address/Phone/Fax*
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Contact Info

Address: 1200 NW 178th St, Ste. 100 Edmond, OK 73012
Get Directions
Phone: (405) 509-2100
4055092288