New Patient Registration| O'Fallon Family Eyecare

Name *

First

Last

Date of Birth *

Day

Month

Year

Address *

Street Address

City

State

Zip

Email *

Phone *

How did you hear about us?

Briefly describe any problems you're experiencing with your eyes or vision.

Do you wear glasses?

Do you wear sunglasses when outdoors?

Do you wear contact lenses?

What brand of contacts do you currently wear?

If 'Other' please indicate the brand/type.

Contact Lens Power - LEFT EYE

Contact Lens Power - RIGHT EYE

Do you have any medical conditions? *

Yes (select conditions below)

None

List any medications you currently take.

List any medications you are allergic to.

Primary care physician name

What is your occupation?

Please list any hobbies or sports you participate in.

Have you ever smoked?

Notice of Privacy Practices

Our Notice of Privacy Practices is a complete description of how O'Fallon Family Eyecare uses and protects your medical information and personal data. If you have not already received a copy of our Privacy Practices, please ask one of our staff members for a printed copy, or we can e-mail it to you in PDF format. By checking this box, you are only acknowledging that you have received a copy of our Notice of Privacy Practices or had the opportunity to review the notice. You can also ask for a copy when you arrive for your appointment.

I have been notified of the privacy practices. *

Yes

Do you want to receive text reminders? *

Yes

No