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.Patient InformationReason for visitName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Date of Birth* MM slash DD slash YYYY 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 Cell PhoneHome PhoneEmail AddressPersonal InformationGender* Female Male Social Security Number (last 4 digits only!)OccupationHobbiesPrimary Physician NamePrimary Physician PhoneOcular HistoryWhen, approximately, was your last eye exam?Have you ever had any of the following? Blepharitis Cataracts Corneal Dystrophy Diabetic retinopathy Dry Eyes Flashes or Floating spots Glaucoma Macular Degeneration Macular epiretinal membrane Narrow angles Ocular Hypertension Migraines Retinal tear Strabismus Patched eye or vision training PVD ( posterior vitreous detachment) Other Ocular History: OtherOcular Surgeries Cataracts Corneal Transplant Intravitreal injection LASIK/PRK Punctal Plugs Retinal Laser Other Cataracts:Date/name of surgeonLASIK/PRK:Date/name of surgeonGlasses HistoryDo you wear glasses?* Yes No When do you wear them?What glasses do you own? Single Vision Bifocals Safety Glasses Backup Glasses Progressive Trifocals Sports Glasses Sunglasses Other Other glasses:Please tell us what other kinds of glasses you own.Contact Lens HistoryDo you wear contact lenses?* Yes No What brand do you wear?How often do you replace them?* Daily 1-2 Weeks Monthly Other Other replacement schedule:Do you sleep in your lenses? Yes No Do you shower or swim in your lenses? Yes No Name of your cleaning system?Do you need glasses over your lenses to help read? Yes No Contact Lens FormIf you wear monthly lenses please read and fill out.Your contact lenses are prescription devices with a limited lifespan. Proper care is necessary for successful wear and good eye health. Please follow instructions carefully. After completing the beginning wear schedule" you should remove your contact lenses every day. Replace contact lenses every 30 days. Before inserting new lenses, allow your contact lenses to rest without any lenses overnight. Clean and disinfect your lenses with BIOTRUE/OPTIFREE contact lens solution. Do not sleep or nap with your lenses on. Never use water on your lenses. Do not put contacts in your mouth. DO NOT shower, bathe or swim with your contact lenses. Do not use contacts in a hot tub. Always carry your contact lens case and glasses when wearing your lenses. BEGINNING WEARING SCHEDULE: (for first time wearers) Day 1 = 4 hours Day 2 = 5 hours Day 3 = 6 hours Day 4 = 7 Hours Day 5 = 8 hours Day 6 = 9 hours Day 7 = 10 hours **Despite current contact lens solution labeling instructions, be sure to rub your contact lenses for one minute on each side with your multipurpose solution or daily cleaner. NEXT APPOINTMENT: as discussed during your eye exam In the beginning it is NORMAL IF: Your eyes itch or feel funny. one lens is more noticeable than the other. vision is fuzzier then with glasses. Vision is better in one eye then the other. REMOVE contacts and call if: You develop redness or pain You develop foggy or cloudy vision You experience a change or decrease in your vision that does not clear up. You suspect something is wrong. Note: Always wash your hands before handling your contacts or eyes. Replace your contact lens case every 2 months. Use cleaning products recommended by Dr. Field to clean and disinfect your lenses. Saline and re-wetting drops are not designed to disinfect your lenses. Generic contact lens solutions are not recommended because they may consist of older formulations and may not properly disinfect your lenses. Additional Notes: How well your eyes adapt to your lenses is a key factor in determining wearing time. DO not exceed the wearing schedule we have prescribed for you. At the end of your wearing cycle, take the lenses out of your eyes and discard them. These brands have been specifically prescribed for your eyes and contacts. Since contacts vary significantly from one brand to another, do not change or substitute solutions unless you check with us first. Use of improper products may result in lens damage or eye irritation. Remember to wash your hands for 20 seconds with soap and water and dry them before handling your contact lenses. Do not touch your face. If you have flu-like symptoms, remove your contact lenses until you feel better. Remember, like any prescription device, contact lenses must be monitored on a regular basis. Professional follow-up care is the most important element in a successful long term lens wear. Please keep your scheduled appointment. I acknowledge that I have received and understand the above instructions on care and handling of disposable and frequent replacement contact lenses. I have also been informed of the necessity for periodic examinations to monitor my eye health and the condition of my contact lenses. I also understand that professional fees are not refundable. It is my understanding that improper use and inadequate care of my contact lenses can cause eye irritation, eye infections and corneal injury.* I acknowledge that all of my questions regarding the contacts, wearing schedule and care have been answered. Contact Lens FormIf you replace your lenses at 2 weeks please read and fill out.Your contact lenses are prescription devices with a limited lifespan. Proper care is necessary for a successful wear and good eye health. Please follow instructions carefully. After completing the "beginning wearing schedule" you should remove your contacts daily. Replace contact lenses every 14 days. Before inserting new lenses, allow your eyes to rest without any contacts overnight. Clean and disinfect your lenses with BIOTRUE/OPTIFREE lens solution. Do not sleep or nap in your contact lenses. Never use water on your lenses. Do not put contacts in your mouth. Do NOT shower, swim, or bathe in your lenses. Do not use contacts in hot tub. Always carry your contact lens case and glasses with you when wearing lenses. BEGINNING WEARING SCHEDULE: Day 1 = 4 hours Day 2 = 5 hours Day 3 = 6 hours Day 4 = 7 hours Day 5 = 8 hours Day 6 = 9 hours Day 7 = 10 hours **Despite your current contact lens labeling instructions, rub your lenses for 60 seconds on each side with your multipurpose solution. There is no more "no rub" contact lens care. NEXT APPOINTMENT: (as discussed during the exam) In the beginning it is NORMAL IF: Your eyes itch or feel funny. One lens is more noticeable then the other. Vision is fuzzier than with glasses Vision is better in one eye then the other eye. REMOVE contacts and call if: You develop redness or pain You develop cloudy or foggy vision You experience a change or decrease in vision that won't clear up. You suspect something is wrong. Note: Always wash your hands before handling your contacts or touching your eyes. Replace your contact lens case every 2 months. use cleaning products recommended by Dr. Field to clean and disinfect your lenses. Saline and re-wetting drops are not designed to disinfect your lenses. Generic contact lens solutions are not recommended because they may consist of an older formulation and may not properly disinfect your lenses. Additional Notes: How well your eyes adapt to your lenses is a key factor in determining wearing time. Do not exceed the wearing schedule we have prescribed for you. At the end of your wearing cycle, remove the lenses from both eyes, and throw them away. These brands have been specifically prescribed for your eyes. Since contacts vary significantly from one manufacturer to another, do not change or substitute solutions unless you check with us first. Use of improper products may result in damage or eye irritation. Remember, like any prescription device, contact lenses must be monitored on a regular basis. Professional follow-up care is the most important element in successful long term wear. Please keep your scheduled appointments. Be sure to wash your hands at least 20 seconds with soap and water and completely dry them before handling your contacts. Do not touch your face Discontinue contact lens wear if you have flu like symptoms. I acknowledge that I have received and understand the above instructions on the care and handling of disposable and frequent replacement contact lenses. I have been informed of the necessity for periodic examinations to monitor the eye health and condition of my contacts. I also understand that professional fees are not refundable. It is my understanding that improper use and inadequate care of my contact lenses can cause possible irritation, infection and corneal injury.* I acknowledge that all of my questions regarding the contacts, wearing schedule and care have been answered. Contact Lens FormIf you replace your lenses daily please read and fill out.Your contact lenses are prescription devices with a limited lifespan. Proper care is necessary for successful wear and good eye health. Please follow directions carefully. Daily disposable lenses are meant to be thrown away after one day use. They are not meant for sleeping, napping or swimming with them on. Once you remove contact lens you may not put it back in your eye. Use re-wetting drops as needed and never put water in your eye. Do not rinse lenses with water and do not put lenses in water. Do not wear contact lenses in a hot tub. Always bring glasses and contact lens case with you when you are wearing contacts. In the beginning it is NORMAL IF: Your eyes itch or feel funny. One lens is more noticeable then the other. Vision is fuzzier than with glasses. Vision is better in one eye then the other. REMOVE contacts and call if: You develop redness or pain You develop cloudy or foggy vision You experience a change or decrease in your vision that does not clear up. You suspect something is wrong. NEXT APPOINTMENT: as discussed during the exam NOTE: How well your eyes adapt to your lenses is the key factor in determining wearing time. Do not exceed the wearing schedule we have prescribed for you. At the end of your wearing cycle, remove the lenses from each eye, and throw them away. These brands have been specifically for your eyes. Since contacts vary from one manufacturer to another, do not change or substitute solutions unless you check with us first. Use of improper products may result in lens damage or eye irritation. Remember to wash your hands with soap and water for 20 seconds and dry them before you handle your contact lenses. Do not touch your face. If you feel ill with flu like symptoms discontinue contact lens wear until you feel better. Remember, like any prescription device, contact lenses must be monitored on a regular basis. Professional follow-up care is the most important element in successful long term lens wear. Please keep your scheduled appointments. I acknowledge that I have received and understand the above instructions on the care and handling of daily disposable contact lenses. I have also been informed of the necessity of periodic examinations to monitor my eye health and the condition of my contacts. I also understand that professional fees are not refundable. It is my understanding that improper use and inadequate care of my contacts can possibly cause eye irritation and corneal injury.* I acknowledge that all of my questions regarding the contacts, wearing schedule and care have been answered. CONTACT LENS COMPLIANCEContact lenses are among the safest forms of vision correction when patients follow the proper care and wearing instructions provided by their eye doctor. However, when patients do not use the lenses as directed, the consequences may be dangerous. In fact, you may be damaging your eyes by not using proper hygiene in caring for your lenses. Contact lenses and the solutions used with them are medical devices and are regulated by the Food and Drugs Administration, therefore, it is extremely important that you maintain regular appointments to ensure you are receiving clinical guidance from your eye doctor based on your individual eye health needs. Clean and safe handling of contact lenses is one of the most important measures that you can take to protect your eyesight. Exercising optimal care and hygiene with contact lenses can keep eyes healthy. Recommendations for Contact Lens Wearers: Always wash (and dry) your hands with soap and water for 20 seconds before handling your contact lenses. Carefully and regularly clean your contacts. Place the contact lens in the palm of your hand and pour some multipurpose solution on the lens. Gently rub for 60 seconds on each side. Rinse the lens. Place the lenses in your contact lens case, fill with multipurpose solution and store overnight. In the morning, rinse the lens before inserting into your eye. Discard the old solutions from the case. Clean the case with multipurpose solution after each use. Do not clean your case with water. Replace the case every 2 months. Use only products recommended by Dr.Field to clean and disinfect your lenses. Saline solution and rewetting drops are not designed to disinfect your lenses. Never use water on your contacts. Only fresh solution should be used to clean and store your contacts. Never reuse old solution. Contact lens solution must be changed everyday, even if lenses are not used daily. Always follow recommended contact lens replacement schedule prescribed by Dr.Field Do not sleep in your contacts. It puts your eyes at risk for infection. Remove your contact lenses before swimming in the ocean or pool, entering a hot tub, bathing, showering, or going to a waterpark. If you are splashed with water or a mist that is contaminated with a virus, fungus, or bacteria, such as pseudomonas, or a parasite such as acanthamoeba, it may get into the lens and infect the eye. An infection may occur which can scar the eye and cause vision loss, blindness, or loss of the eye. Always carry your contact lens case, glasses, and a bottle of multipurpose solution with you when you are wearing your contacts. If you must remove your lenses and are unable to re-insert them, you will have a place to store and will have your glasses as a back-up. If you are not wearing your contact lenses every day, you must still discard them at the end of your wearing schedule. You may not extend the life of the lens. Do not smoke or be in the presence of second hand smoke. Contacts can absorb the chemicals and cause an eye infection or corneal ulcer resulting in vision loss. If you are ill, discontinue contact lens wear until you are well. Discard that pair and start with a new one. See Dr. Field for your regularly scheduled contact lens exams and follow-ups. If you have any unexplained eye pain or redness, watering of the eyes or discharge, cloudy or foggy vision, decrease in vision or increased sensitivity to light, remove your contacts and make arrangements to see Dr.Field immediately.I acknowledge that I have read items 1-11 above and all of my questions regarding contact lenses, wearing schedule, and care of contacts have been answered. * I acknowledge and accept the above contact lens compliance. Medical HistoryDate of last physicalPlease check off any conditions you suffer from Anxiety Anthritis Asthma Atrial Fibrillation Autoimmune disease (Lupus) Cancer COPD COVID Heart issues Diabetes Headache/migraine HIV/AIDS Leukemia Lymphoma Pregnant or Nursing Radiation treatment Seizures Stroke Thyroid problems Other Other Condition/s:Please list past surgeries:Please list all medications:Please list any seasonal allergies:Please list any drug allergies:Please list family history of eye disease or health issues:Do you smoke currently? Yes No Have you smoked in the past? Yes No Do you drive? Yes No Have you had Flu vaccine? Yes No Have you had pneumonia vaccine? Yes No Primary InsurancePlease bring all insurance cards with you to your appointment.Insurance Company NameInsurance Company Phone NumberInsured's Name First Last Identification NumberGroup NumberInsured's Date of Birth MM slash DD slash YYYY Patient's Relation to InsuredSecondary InsuranceDo you have secondary insurance? Yes No If you have coverage through another plan/organization, please fill in the details below.Insurance Company NameInsurance Company Phone NumberInsured's Name First Last Identification NumberGroup NumberInsured's Date of Birth MM slash DD slash YYYY Patient's Relation to InsuredCommentsIf you have any comments you would like to add, please enter them here.Privacy PolicyHealth Information Protection* I have read and agree to the Privacy Policy CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ
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