Patient Registration Form New

"*" indicates required fields

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.

Location*

Colorado Springs

Falcon

Windsor

Patient Information

Name*

Prefix First Last Suffix

Nickname

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Please provide a telephone number, with area code, so we can contact you.

Daytime Phone

Cell Phone

Can we text you on your mobile number?

Yes

Email Address

Please provide us your email address.

Personal Information

Gender*

Female

Male

Date of Birth*

Drivers License

Max. file size: 31 MB.

Social Security Number

State or Military ID front

Max. file size: 31 MB.

State or military ID back

Max. file size: 31 MB.

Marital Status

Marital Status - Other

Please provide your marital status.

Employment Status

Employment Status - Other

Please provide your employment status.

Employer

Occupation

How were you referred to our office?

Referral Status - Other

Please let us know how you were referred to our office.

Communication Preference

Vision Insurance

Insurance Company Name*

Primary Insured's Name*

First Last

Primary Insured's Date of Birth*

Primary Insured's SSN

Primary Insured's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Insured's Phone Number

Insurance Identification Number

Insurance Group Number

Patient's Relation to Insured

Primary Medical Insurance

Insurance Company Name*

Please bring all insurance cards with you to your appointment.

Primary Insured's Name*

First Last

Primary Insured's Date of Birth*

Primary Insured's SSN

Insurance card - front

Max. file size: 31 MB.

Insurance card -back

Max. file size: 31 MB.

Primary Insured's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Insured's Phone Number

Insurance Identification Number

Insurance Group Number

Patient's Relation to Insured

Secondary Medical Insurance

Do you have secondary insurance?

Yes

If you have coverage through another plan/organization, please fill in the details below.

Insurance Company Name*

Primary Insured's Name*

First Last

Primary Insured's Date of Birth*

Primary Insured's SSN

Primary Insured's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Insured's Phone Number

Insurance Identification Number

Insurance Group Number

Patient's Relation to Insured

Eye History

Please check off any current conditions you suffer from

I stopped wearing glasses because:

I stopped wearing contact lenses because:

Retinal Imaging/Dilation Consent

Are you coming in for a routine eye exam?*

Yes

Retinal Imaging/Dilation Consent*

I have read and understand all terms

Please check one of the following:*

I would like to have my eyes dilated today

I decline to have my eyes dilated

Please check one of the following:*

$39 for routine Retinal Imaging

$79 for lifetime Retinal Imaging

I decline Retinal Imaging

I have already paid for lifetime retinal imaging.

Glasses History

Do you wear glasses?*

Yes

Eyeglasses Agreement*

I have read and understand all terms

What glasses do you own?

Other glasses:

Please tell us what other kinds of glasses you own.

How many hours a day do you use a computer?

Please enter a number from 0 to 24.

How many inches away, approximately, do you sit from your computer monitor?

Please enter a number from 0 to 120.

Please check off any current conditions you suffer from

I am having problems with my current glasses

There are times when I would rather not be wearing glasses

I have problems with glare

I have problems with night vision

I am allergic to nickel (e.g. frames of glasses)

I don’t have spare set of glasses

My spare glasses have an incorrect prescription

My sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Is this a contact lens exam?*

Yes

Alpine Vision Contact Lens Consent, Fitting, Agreement, and Return Policy*

I have read and understand the Consent, Fitting Agreement, and Return Policy

Contact Lens Wear Schedule and Instructions*

I have read and understand all terms

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

Please enter a number from 0 to 24.

What is your typical wearing schedule? In days per week:

Please enter a number from 0 to 7.

Please check off all that apply to you

I am having problems with my current contact lenses

There are times when I would rather not be wearing contact lenses

I am interested in changing or enhancing my eye color

I am interested in a non-surgical method of vision correction

I am interested in refractive laser surgery

I don't have a spare set of contact lenses

My spare contact lenses have an incorrect prescription

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 drink alcohol?

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

Comments

If you have any comments you would like to add, please enter them here.

Privacy and Financial Policy

Financial and HIPAA Agreement*

I have read and agree to the Privacy Policy

Hidden

Financial Policy*

I have read and agreed to the Financial Policy.

Patient Name*

First Last

Patient Signature*

Acknowledgement and Agreement*

By clicking "Submit", I understand and agree that I am electronically signing all above documents and that all the included information is true and correct to my knowledge.

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