8136 Wiles Rd. Coral Springs, FL 33067

(954) 757-2468

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Patient Form
 
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Welcome to online registration for Optical Eyeworks. Please take a moment to fill out this information. It will help us better assist you on the day of your appointment. If you need assistance with this, please call us at (954)757-2468. Completing this information will assist us in providing eye care custom designed for your particular needs.
 

Patient Information
Name * :
Date of Birth :
Salutation :
Street Address :
City :
State :
Zip :
Home Phone :
Mobile * :
Work Phone :
Email * :
Vision Insurance Information
Please complete this so we may verify your benefits before your visit. Enter the insured person first name (primary member covered), date of birth and place of employment. You will need to look at your insurance card to complete this.
Insurance Company : Or Other
Insurance Member Name :
Member Date of Birth :
Insurance ID :
Relationship to Patient * :
Referral Information
Whom may we thank for referring you? Our "Share the Care" program offers substantial savings for referring friends and family.
Doctor Referral :
Patient Referral :
Internet Search :
Insurance Company :
MEDICAL RECORDS
Medications
Medication Name :
Date Started :
Use :
Allergies
Name of Allergy :
Reaction :
Severity :
Onset :
Type :
If Diabetic
When were you diagnosed as diabetic? :
Blood Sugar :
Date of Last Blood Sugar :
Self Monitoring Blood Sugar :
HbA1C :
HbA1C Time :
Ocular History
Glaucoma :
Cataracts :
Macular Degeneration :
Eye Injury :
Retinal Disease :
Other Eye Disease :
Blindness/ Vision Loss :
Strabismus :
Amblyopia :
Ocular Complications Related to Diabetes :
Dry Eye :
Wear Glasses or Contacts :
Other :
Family History
Family History of Glaucoma :
Cataracts :
Macular Degeneration :
Eye Injury :
Retina Disease :
Other Eye Disease :
Strabismus :
Amblyopia :
Blindness/ Vision Loss :
Diabetes :
Cancer :
Heart Disease :
Other Family History :
 
 
 

Mon.

N/A

10:00 AM to 1:00 PM

Tue.

Wed.

1:00 PM to 7:30 PM

9:30 AM to 5:30 PM

Thu.

Fri.

N/A

9:30 AM to 4:00 PM

Sat.

 
 
 
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