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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.

Office Location

Salutation

Patient First Name

Patient Middle name

Patient Last Name

Suffix

Date Of Birth

Age

Address

Apartment/Suite

City

State

Zip

Phone

Alternate Phone

Contact's Email

Patient Occupation

Patient Employer

Work Phone

Patient Social Security

Primary Insured Social Security

Is this your first visit to our office?

Yes

If yes, please tell us who referred you:

Please tell us the reason(s) for your upcoming visit: (Check all that apply)

Eye health problem (cataracts, glaucoma, macular degeneration

Blurry vision

Need new glasses

Need new contacts

Laser vision consultation

Health concern (e.g diabetes, hypertension, thyroid, lupus, etc)

Annual Exam

Other, please explain:

Do you currently wear contact lenses?

Yes

If you participate in any sports list them here:

Insurance Information

Health Insurance company (include Medicare / Medicaid)

Health Insurance policy #

Vision plan (e.g. VSP, Eye Med, Davis, Spectera)

Vision plan policy #

Book appointment Order Contacts

at Pearle Vision

Patient Forms

Book Appointment

Email Sign-Up

Read Our Blog...

Patient Registration and Health History

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

General Health Condition

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

select from list

or type here...

Drug Allergies

Contact our Pearle Vision locations

Book appointmentOrder Contacts

at Pearle Vision

Patient Forms

Book Appointment

Email Sign-Up

Read Our Blog...

Patient Registration and Health History

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

General Health Condition

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

select from list

or type here...

Drug Allergies

Contact our Pearle Vision locations

Book appointment Order Contacts