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.
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Patient Information

Name*
Prefix
First
Last
Suffix
Address*
Street Address
Address Line 2
City
State/ Province/ Region
Zip/ Postal Code
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*
Date of Birth*
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

Communication Preference

Eye History

Please check off any current conditions you suffer from

Glasses History

Do you wear glasses?

Contact Lens History

Do you wear contact lenses?

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​​​​​​​

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name
Insurance Company Phone Number
Address
Street Address
Address Line 2
City
State/ Province/ Region
ZIP/ Postal Code
Insured's Name
First
Last
Identification Number
Group Number
Insured's Date of Birth
Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Comments

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

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Health Information Protection*
Signature*
Date*

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Roya1234 none 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM 9:00 AM - 6:00 PM 8:00 AM - 5:00 PM 8:00 AM - 12:00 PM Closed optometrist https://www.google.com/search?q=609+N+Halleck+St.+%E2%80%8BDeMotte%2C+IN+46310+DE+BOER+FAMILY+EYECARE&sxsrf=ALeKk02hA2D_DDR5pVmwIoE1jr-IBqtDZQ%3A1618545264229&ei=cAp5YMvRDanWmAXX557QDw&oq=609+N+Halleck+St.+%E2%80%8BDeMotte%2C+IN+46310+DE+BOER+FAMILY+EYECARE&gs_lcp=Cgdnd3Mtd2l6EANQ8lVY41dgq1loAXAAeACAAZABiAHJApIBAzIuMZgBAKABAaABAqoBB2d3cy13aXrAAQE&sclient=gws-wiz&ved=0ahUKEwjLyZv87oHwAhUpK6YKHdezB_oQ4dUDCA4&uact=5#lrd=0x8812204b6b5195e3:0xac0150d52451fbc6,3,,, https://www.yelp.com/writeareview/biz/wbR3meGjXyyiHQK1tb7Vmg?return_url=%2Fbiz%2FwbR3meGjXyyiHQK1tb7Vmg&source=biz_details_war_button https://www.facebook.com/DeBoerFamilyEyecareDeMotte/reviews/?ref=page_internal https://www.google.com/maps/embed?pb=!1m14!1m8!1m3!1d12006.479910674887!2d-87.198339!3d41.208258!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x0%3A0xac0150d52451fbc6!2sDe%20Boer%20Family%20Eye%20Care!5e0!3m2!1sen!2sph!4v1618548639138!5m2!1sen!2sph https://g.page/de-boer-family-eye-care-demotte?share Enable https://s3.amazonaws.com/static.organiclead.com/Site-5d679226-2b96-45e7-848c-9de93a89b07f/Deboer_Q4_BetweenSeasonsSale_socialpost.png