Patient Registration and Health History

For your convenience, you can choose to complete this form online to save time at your visit to Chicago Eye Doctors.

All information entered is secure in compliance with HIPPA regulations

Completing and submitting the following information prior to your appointment will help us make your visit more punctual and thorough.

Office Location

Salutation

Patient First Name

Patient Middle Name

Patient Last Name

Suffix

Date of Birth

Age

Address

Apartment/Suite

City

State

Zip

Phone

Alternate Phone

Contact Email

Patient Occupation

Patient Employer

Work Phone

Patient Social Security

Primary Insured Social Security

Is this your first visit to our office?
YesNo

If yes, please tell us who referred you:

Please tell us the reason(s) for your upcoming visit: (Check all that apply)

Eye health problem (cataracts, glaucoma, macular degenerationBlurry visionNeed new glassesNeed new contactsLaser vision consultationHealth concern (e.g diabetes, hypertension, thyroid, lupus, etc)Annual Exam

Other reasons:

Do you currently wear contact lenses?
YesNo

If you participate in any sports list them here:

Insurance Information

Health Insurance company (include Medicare / Medicaid)

Health Insurance policy #

Vision plan (e.g. VSP, Eye Med, Davis, Spectera)

Vision plan policy #

Primary Insured First Name

Primary Insured Last Name

Insurance Information

Are you pregnant?
YesNo

Nursing?
YesNo

Medical History

A thorough eye exam and all insurers require a complete medical history. Please check all that apply. Please leave boxes unchecked for a NO answer.

Eye History

General Health Condition

Please provide your family doctor's name, address and contact information:

Family History

Currently taking medication(s) - prescription and/or over the counter

Select from list

or type here...

1.I take

reason:

2.I take

reason:

3.I take

reason:

4.I take

reason:

5.I take

reason:

If you take additional medications, please list them here:

Drug Allergies

Do you have any drug allergies?
YesNo

If yes, please list the medication(s):

Patient Forms

Read Our Blog…

Patient Registration and Health History

All information entered is secure in compliance with HIPPA regulations

Patient Forms

Read Our Blog…

Patient Registration and Health History

All information entered is secure in compliance with HIPPA regulations

Contact our Pearle Vision locations