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ONLINE REGISTRATION
Registration Form
Name
Name
First
First
Last
Last
Date of Birth
Gender
Male
Female
Other
Parent/Guardian Name
Address
City
State
Zip
Phone Number
Cell Phone Number
Work Number
Emergency Contact Number
Email
Occupation
Name of Insurance Plan
Name of Primary Subscriber
Group Number
Policy Number
Employer
Text
Relationship to Subscriber
Self
Spouse
Child
Other
Medical History – List all meds and surgeries
Medical Conditions
Hypertension
Diabetes
High Cholesterol
Heart Disease
Seizures
Migraines/Headaches
Cancer
__________
Bleeding Problems
Thyroid
Rheumatoid Arthritis
Deaf
Cognitive Impairment
Sleep Apnea
Muscle/Joint Pains
Ocular Conditions
Loss of Vision
Distance Blur Vision
Near Blur Vision
Distortion/Halos
Dry Eyes
Discharges from Eye
_____________
Red Eyes
Growth on Eyes
Itchy Eyes
Foreign Body
Tearing
Glare/Light Sensitivity
Family History
Blindness
Crossed Eyes
Macular Degeneration
Glaucoma
Retinal Detachments
_____________
Diabetes
Heart Disease
Kidney Disease
Cancer
Thyroid Disease
If you are human, leave this field blank.
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