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.

Patient Information

Name *

Address*

Phone Number *

Daytime Phone

Cell Phone

Email Address *

Personal Information

Gender

Female Male

Date of Birth *

Social Security Number

Preferred Language *

Race *

Ethnicity *

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference

Glasses History

Do you wear glasses?

Yes No

Contact Lens History

Do you wear contact lenses?

Yes No

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

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insurance Company Phone Number

Address

Insured's Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Yes No

Comments

Privacy Policy

Health Information Protection

I have read and agree to the Privacy Policy Not Agree

Signature*

Date

Please do not submit any Protected Health Information (PHI).

EyeLove Family Eye Care & Optical

Address

4362 North Waterside Court #110,
Fayetteville, AR 72703

Phone

(479) 521-6460

We look forward to hearing from you

Please do not submit any Protected Health Information (PHI).

Our Hours

Monday

8:00 am - 5:00 pm

Tuesday

8:00 am - 5:00 pm

Wednesday

8:00 am - 5:00 pm

Thursday

8:00 am - 5:00 pm

Friday

8:00 am - 12:00 pm

Saturday

Closed

Sunday

Closed

Address
4362 North Waterside Court #110,
Fayetteville, AR 72703 US

(479) 521-6460

Location

Location

Patient Registration Form

Patient Information

Personal Information

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Privacy Policy

EyeLove Family Eye Care & Optical

We look forward to hearing from you

Our Hours