Patient Registration Form Vision Care Name* First Last Preferred Name Date of Birth SK Health NumberFamily MembersAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone (Home)Phone (Mobile)Phone (Work)Occupation/SchoolEmployer/TeacherEmail Eye HistoryReason(s) for today's visit?Date of last eye examPrevious Optometrist / ClinicAre you currently under the care of an ophthalmologist? Yes No If yes, who?Do you wear contact lenses Yes No If yes, how often do you wear your contacts?Contact lens brand?Contact lens cleaning solutionDo you currently wear Rx Sunglasses? Yes No Do you use eye drops? Yes No If yes, what brand?Please check all of the following symptoms and history points that are applicable Blurry distance vision Poor night vision Eye Strain Blurry near vision Trouble reading Itchy eyes Discharge Watering Pain in the eye Burning eyes Tired or dry eyes Red eyes Glare/Reflections light sensitivity Double vision Floaters or spots in your vision Flashes of light An eye injury History of eye patching History of vision training History of eye surgery Headaches OtherMedical HistoryFamily DoctorMedical SpecialistsAllergiesList of medical conditionsList of medications, vitamins and supplementsList known family eye historyList personal relevant eye historyI authorize the following individuals to obtain information regardingmy appointments,status updates,and spectacle prescription inquiries: (Example:Spouse,child,friend,child care provider,etc)Written delegates(s)Doctor Vision Caare has offered to communicate using the following means of electronic communication for recalls,appointment confimations,notifications and promotions. (Check all that apply) E-Mail Text Messaging Social Media Other Specify
