Patient Registration Form Today's Date MM slash DD slash YYYY Patient InformationName First Middle Last Nickname First Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneEmail Address Sex Male Female Date of Birth MM slash DD slash YYYY Age Patient's SSN Employer (or School) Occupation (or Grade) Spouse (or Parent's Name) What is the major purpose of this visit?Any problems with your current contact lenses or glasses?Are you planning on getting glasses and/or contacts today?Brunswick Eye And Contact Lens Policies Orders can only be cancelled at no cost if the lab has not yet started them. If you choose to use your own frame, Brunswick Eye will not be responsible if the frame is lost or damaged during transit to and from the labs. If you bring in a frame to be adjusted that you purchased elsewhere, or if the frame that you purchased here is past warranty, we will not be held responsible if it breaks. You are fully responsible for charges which exceed your insurance benefits. (ABN) Outstanding balances are subject to interest charge of 1.5% per month. Brunswick Eye charges $25 for returned checks. Insurance InformationPlease note that most insurance companies do NOT cover the Contact Lens Evaluation.Vision Insurance Subscriber Name Subscriber SSN Subscriber Birth Date MM slash DD slash YYYY Primary Medical Insurance Subscriber Name Subscriber SSN Subscriber Birth Date MM slash DD slash YYYY Do you participate in a flex spending account? Yes No How will you settle your account today? Cash Check Credit Card Care Credit Lifestyle QuestionsDo you (check box if your answer is yes) ..work at a computer? ..think you might benefit from thinner, lighter lenses? ..have interest in the latest contact lens designs? ..spend a significant time outdoors? ..have prescription sunwear? ..want information on Laser Vision Correction surgery? ..have more than 1 pair of current Rx eyewear? ..have children? ..have family members in need of eyecare? Have you ever experienced, been diagnosed or treated for any of the following? Blurry Vision Burning Cataracts Corneal Abrasions Crossed eye/Eye turn Double Vision Eye Infections Eye Injury Flash of light Floaters/Spots Glaucoma Grittiness Headaches Iritis/Uveitis Itchiness Lazy Eye Macular Degeneration Occasional dryness Retinal Detachment Sunlight Sensitivity Tearing Trouble seeing at night Uncomfortable glasses Other eye disorders How did you hear about us? Who can we thank for referring you to our office? Name The information in this confidential case history form is critical to the evaluation of your vision and health. Patient Medical HistoryName of Family Physician Town Date of Last Physical Check-up MM slash DD slash YYYY Have you had any eye surgeries? Yes No Do you use/consume...DailyNeverOccasionallyCigarettes/tobacco?Alcoholic beverages?Recreational drugs?Have you ever been diagnosed or treated for the following health problems?*YesNoAllergiesArthritisBlood/LymphCancerCholesterolDiabetesDigestiveEars/Nose/ThroatHigh Blood PressureIntegumentary (Skin)KidneyMuscle/BoneNeurologicalPsychologicalRespiratoryThyroidUnusual weight losses/gainsOther CURRENT MEDICATIONS (Rx or Over the Counter)(List name of medications including eye drops, vitamins, & birth control pills) Allergies to medications? Yes No If yes so, what medications? Patient Eye HistoryDate of Last Eye Exam MM slash DD slash YYYY By Whom? Have you ever tried contact lenses? Yes No Do you currently wear contact lenses? Yes No What kind? Solutions used Are you satisfied with the vision and comfort of your contact lenses? Yes No Would you prefer clear contact lenses or colored contact lenses? Clear Colored Do you wear sunglasses or lenses that change outdoors? Yes No Family Medical/Eye History (Check all that apply)Is there a family medical history of any of the following: Yes (Please check boxes) No Cataracts Yes No Relationship to patient Corneal Problems Yes No Relationship to patient Glaucoma Yes No Relationship to patient Lazy Eye Yes No Relationship to patient Macular Degeneration Yes No Relationship to patient Retinal Problems Yes No Relationship to patient Diabetes Yes No Relationship to patient Heart Disease Yes No Relationship to patient Cholesterol Yes No Relationship to patient Hypertension Yes No Relationship to patient Please be advised if you are using insurance coverage for today's visit, this is a contract between you and your insurance company...not Brunswick Eye and Contact Lens Center. You are fully responsible for the extra charges that the insurance does not cover. If your insurance company has not reimbursed our office in full within 60 days, you will receive an invoice for outstanding balances. (If by mistake your insurance company sends the payment check to us, we will of course sign over and forward the check directly to you.) We appreciate your trust in us!! From the staff at Brunswick Eye and Contact Lens Center SignatureName First Last