Patient Registration Form

Patient Registration Form

Patient Registration Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.
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Name*
Address*
Phone Number*
Please provide a telephone number, with area code, so we can contact you.
Daytime Phone
Cell Phone
Email Address*
Please provide a telephone number, with area code, so we can contact you.

Personal Information

Gender*
Date of Birth*
Social Security Number (last 4 digits only!)
Preferred Language*
Race*
Ethnicity*
Marital Status*
Employment Status
Employer
Occupation
How were you referred to our office?
Communication Preference

Eye History

Please check off any current conditions you suffer from
I stopped wearing glasses because:
I stopped wearing contact lenses because:

Glasses History

Do you wear glasses?*

Contact Lens History

Do you wear contact lenses?*

Medical History

When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any current conditions you suffer from

Primary Insurance

Please bring all insurance cards with you to your appointment.
Insurance Company Phone Number
Identification Number
Group Number
Insured's Date of Birth
Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Comments

Privacy Policy

Health Information Protection*
Date
Roya1234 none 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM Closed Closed optometrist # # https://www.facebook.com/Dr-Tonya-D-Lindsell-AssociatesLLC-351404585070121/reviews/?ref=page_internal 7800 Montgomery Rd Ofc,
Cincinnati, OH 45236, United States 5137935970 5137935976 https://goo.gl/maps/oTZmdKPMmA1xY4FGA Monday to Saturday
10:00AM - 6:00PM

Sunday
12:00pm - 4:00PM 7630 Blake St,
Liberty Township, OH , 45069 5137125065 5137551741 https://goo.gl/maps/FPMoTMoqiFWPdKpN7 Monday to Saturday
10:00AM - 6:00PM

Sunday
12:00pm - 4:00PM 4601 Eastgate Blvd C578,
Cincinnati, OH 45245 5137534981 5137530371 https://goo.gl/maps/xyoEwBMg8EdMvqRh7 Monday to Saturday
10:00AM - 6:00PM

Sunday
12:00pm - 4:00PM