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Brattleboro Family Eye Care

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Hours & Location
Our Eye Care Clinic
- Our Eye Doctors
- The Staff
Eye Care Services
Eyeglasses
- Designer Frames
- Our Lab
Contact Lenses
- Contact Lens Rebates
- Our Featured Brands
Insurance

Home » Contact Us » 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.
Patient Information
Name*
Prefix First Last Suffix
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
- I would like to receive text message confirmations.
- I would not like to receive text message confirmations.
Email Address*
- I would like to receive email confirmations.
- I would not like to receive email confirmations.
Personal Information
Gender Indentification*
- Female
- Male
Preferred Pronouns
- She/Her
- He/His
- They/Them
Date of Birth*
MM slash DD slash YYYY
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*
- None
- Headaches
- Glare/Light Sensitivity
- Tired Eyes
- Amblyopia (lazy eye)
- Burning
- Dryness
- Watery Eyes
- Eye Pain and/or Soreness
- Foreign Body Sensation
- Infection of Eye or Lid
- Itching
- Discharge From Eyes
- Drooping eyelid(s)
- Redness
- Sandy or Gritty Feeling
- Strabismus (crossed eye)
- Lazy Eye
- Blurred Vision at Distance
- Blurred Vision at Near
- Halos
- Double Vision
- Floaters or Spots
- Fluctuating Vision
- Loss of Side Vision
- Macular Degeneration
- Glaucoma
- Cataracts
Do you use lubricating eye drops?
- Yes
- No
Glasses History
Do you wear glasses?*
- Yes
- No
Do you think you need glasses?
- Yes
- No
Why?
- My vision is blurry in the distance.
- My vision is blurry up close.
- My vision is blurry in the distance and up close.
What glasses do you own?*
- Single Vision Distance
- Single Vision Reading
- Bifocals
- Safety Glasses
- Progressive
- Trifocals
- Sports Glasses
- Sunglasses
- R
Other glasses:

Please tell us what other kinds of glasses you own.
Please check all that apply.*
- I am satisfied with my glasses.
- I am not satisfied with my glasses.
- I wish to improve the distance correction.
- I wish to improve the near correction.
- (Progressives) I wish to improve the middle-range.
- My lenses are heavily scratched.
- I would rather not wear glasses.
- I would like to update my frames and lenses.
- I would like to update my lenses and keep my old frames.
How many hours a day do you use a computer or other digital devices?
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.
Contact Lens History
Do you wear contact lenses?*
- Yes
- No
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 all that apply.*
- I do not wear contacts.
- I am interested in trying contacts.
- I'm not having any issues and am satisfied with my lenses.
- 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 a non-surgical method of vision correction
- I am interested in changing or enhancing my eye color
- 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 tobacco?*
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.). If none, write "none" or "N/A."*
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment). If none, write "none" or "N/A."*
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.). If none, write "none" or "N/A."*
Please list all prescription and over-the-counter medications or vitamins you take. If none, write "none" or "N/A."*
Please list all drug allergies you have. If none, write "none" or "N/A."*
Please list all hospital surgeries you have ever had. If none, write "none" or "N/A."*
Please check off any current conditions you suffer from. If none, please select "N/A or NONE".*
- N/A or NONE
- Chronic fever, unexpected weight loss/gain, fatigue
- Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)
- Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)
- Respiratory problems (eg. Shortness of breath, wheezing, coughing)
- Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
- Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)
- Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)
- Skin problems (eg. Rashes, excessive dryness, growths or lumps)
- Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)
- Psychiatric problems (eg. Depression, anxiety)
- Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)
- Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)
- Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)
Primary Insurance
Do you have insurance?*
- Yes
- No
***** Please bring all insurance cards with you to your appointment. *****
Insurance Company Name*
Insured's Name*
First Last
Identification Number*
Group Number
Insured's Date of Birth*
MM slash DD slash YYYY
Patient's Relation to Insured*
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Comments
If you have any comments you would like to add, please enter them here.
Financial Responsibility
I understand that most insurance policies pay only a portion of the total charges and if I have questions about my coverage I will contact my insurance representative. Brattleboro Family Eye care can not guarantee the accuracy of benefit information given to them by insurance companies. I authorize the release of any medical or other information necessary to process insurance claims. I authorize payment of medical or vision benefits either to the physician or supplier of services rendered or to myself if the provider does not accept assignment. I understand that I am responsible for any balance my insurance does not pay. Payment (including deductibles, co-pays, and non-covered services) is expected at the time services are provided. Any balances that are beyond 60 days past due are subject to an 18% annual interest rate. By signing below, I acknowledge that I have read and agree to the information on this form.
I acknowledge that I have read the above information*
To sign : Draw your signature in the box using a mouse or finger.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Phone
This field is for validation purposes and should be left unchanged.

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Brattleboro Family Eye Care

328 Western Avenue
Brattleboro, VT 05301

Phone: 802-254-9012
Fax: 802-251-1076

Monday: 8:30 AM - 5:00 PM
Tuesday: 8:30 AM - 5:00 PM
Wednesday: 8:00 AM - 5:00 PM
Thursday: 8:30 AM - 5:00 PM
Friday: 8:00 AM - 3:00 PM
Saturday: Closed
Sunday: Closed

Hours & Location
Our Eye Care Clinic
Eye Care Services
Eyeglasses
Contact Lenses
Insurance

Hours & Location
Our Eye Care Clinic
Eye Care Services
Eyeglasses
Contact Lenses
Insurance

Home
Contact Us
Disclaimer
Privacy Policy

Home
Contact Us
Disclaimer
Privacy Policy

Brattleboro Family Eye Care - Located at 328 Western Avenue, Brattleboro, VT 05301 Phone: 802-254-9012 http://www.brattleborofamilyeyecare.com

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Appointments

While our doors are open to serve you, we kindly request that all patients schedule an appointment for glasses ordering, adjustments, and repairs. If you would like to sit down with an optician when picking up your glasses, please make an appointment in advance to minimize your wait time.