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Patient Registration Form

New Patient Form

Name
First Last
Phone
Email
Optional Test
- I would like to have both additional screening tests done
- I would like to have just the retinal photographs taken
- I would like to have just the visual field test done I would
- I would not like to have either optional test done
How did you hear about us?
- Previous Patient
- Referred by friend/family
- Referred by insurance
- Walk-in
- Advertisement
Whom may we thank:
Advertisement
- Valpak
- Merchandiser
- Gazette
- Giant
- Courier
- VOU message board
- Other
Other
Social History
Recreational Activities:
- Sports (indoor)
- Sports (outdoor)
- Video games
- Reading
- Alchohol Consumption:
- Video games
- Computer Use
- Tobacco Consumption
Sports (indoor) Frequency
Sports (outdoor):Frequency
Video games: Frequency
Reading: Frequency
Alcohol Consumption: Frequency
Tobacco Video Games: Frequency
Computer Games: Frequency
Patient Comments:
Glasses and Contact Lenses
- Glasses for distance only
- Glasses for near/reading only
- Glasses for full-time wear
- Soft contact lenses
- Rigid contact lenses
- No previous glasses or contact lenses
Check all that apply and explain
Explain
Laser or Eye Surgery
Check all that apply and explain
- NO laser or ocular surgery
Explanation
Past Eye Conditions and Injuries
Check all that apply and explain
- NO past illnesses or injuries
Conditionsor Injuries:
Eye Medications
Check all that apply and explain
- NO personal eye medications
Explanation
Personal Eye Diseases
Check all that apply and explain
- NO personal eye diseases
- Cataracts
- Glaucoma
- Detached Retina
- Diabetic Retinopathy
- Macular Degeneration
- Turned Eye (strabismus)
- Lazy Eye
- Eye Injury
- Other
Explanation
Family Eye Diseases
Check all that apply and explain
- NO family eye diseases
- Cataracts
- Glaucoma
- Detached Retina
- Diabetic Retinopathy
- Macular Degeneration
Explain
General Health History
Check all that apply and explain
- Fever or weight loss
- Ears, mouth, nose, throat problems
- Sinus disease
- High blood pressure
- Irregular heart beat
- Other heart disease
- Asthma or emphysema
- Other lung disease
- Diabetes or thyroid disease
- Stomach or intestinal problems
- Kidney, urinary or genital disease
- Joint or muscle pain
- Skin disorders
- Headaches
- Stroke or neurological disease
- Blood disorders
- HIV or AIDS
- Seasonal allergies
- Reaction to anesthetics
- Psychiatric problems
- Do you smoke cigarettes
- Other current health problems
Explanation
Current Medications
Check all that apply and explain
- NO current medications
Explanation
Allergies to Medicines
Check all that apply and explain
- NO allergies to medicines
Allergy:
Past Surgeries (cardiovascular/brain/thyroid)
Check all that apply and explain
- NO past surgeries
Past Surgeries:
Family Medical Diseases
Check all that apply and explain
- NO family medical diseases
- Family high blood pressure
- Family cancer
- Family neurological disease
- Family diabetes
Explanation

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V. Eye.P. EyeCare – Villages of Urbana

3540 Sugarloaf Parkway Unit D-4
Frederick, MD 21704

Phone: 301-874-5777
Fax: 240-341-2186
Email: amanda@veyepeyecare.com
(Do not send personal health information by email.)

Monday: 12:00 PM - 8:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 12:00 PM - 8:00 PM
Thursday: 9:00 AM - 5:00 PM
Friday: 9:00 AM - 5:00 PM
Saturday: 9:00 AM - 5:00 PM
Sunday: Closed

V. Eye. P. EyeCare – Clarksburg Village

22610 Newcut Road Suite E4-A
Clarksburg, MD 20871

Phone: 301-874-5777
Fax: 240-477-5827
Email: amanda@veyepeyecare.com
(Do not send personal health information by email.)

Monday:9:00am-5:00pm
Tuesday:9:00am-5:00pm
Wednesday:9:00am-5:00pm
Thursday:9:00am-5:00pm
Friday:9:00am-5:00pm
Saturday:Closed
Sunday:Closed

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V. Eye. P. EyeCare – Clarksburg Village
22610 Newcut Road Suite E4-A
Clarksburg, MD 20871
Phone: 301-874-5777
https://www.veyepeyecare.com

V. Eye.P. EyeCare – Villages of Urbana
3540 Sugarloaf Parkway Unit D-4
Frederick, MD 21704
Phone: 301-874-5777
https://www.veyepeyecare.com

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