Patient Registration and Health History

For your convenience, you can choose to complete this form online to save time at your visit to Chicago Eye Doctors.

All information entered is secure in compliance with HIPPA regulations

Completing and submitting the following information prior to your appointment will help us make your visit more punctual and thorough.


Insurance Information

Required by Insurance


Medical History

A thorough eye exam and all insurers require a complete medical history. Please check all that apply. Please leave boxes unchecked for a NO answer.

General Health Condition


Currently taking medication(s) - prescription and/or over the counter

select from list

or type here...


Drug Allergies