Online Patient Registration Form

Is the patient also responsible for the account? Yes No *

Contact Info

Patient Contact Information

Last Name *

First Name *

MI *

Date of Birth (DOB) *

Gender *

Address *

City *

State *

Zip Code *

Telephone # *

May we contact you via e-mail? Yes No *

E-mail Address *

Insurance Information

Vision Insurance Information

Insurance Company Name *

Provider phone # listed on card *

Name of Insured (Policy Holder) *

ID/Policy/Subscriber Number *

Group or Employer Name *

Policy Holder's DOB *

Patient's Relation to Insured *

Medical Insurance Information

Insurance Company Name *

Provider phone # listed on card *

Name of Insured (Policy Holder) *

ID/Policy/Subscriber Number *

Group or Employer Name *

Policy Holder's DOB *

Patient's Relation to Insured *

Reason(s) for today's visit? (1200 chars left) *

Please check if you experience any of the following: Dry Eyes
Burning
Excessive Tearing
Foreign Body Sensation
Eyes Itch
Light Sensitivity
Visual Discomfort
Eye Strain
Eye Pain
Blind Spots
Transient Vision Loss
Loss of Central or Side Vision
Sudden Vision Loss
Double Vision
Floaters
Light Flashes
Frequent Headaches
Drooping Eyelid(s)
Eye Turn (In or Out)

Please describe any other problems you're having not listed above (1200 chars left)

Eyeglasses and Contact Lenses

Do you currently wear glasses? Yes No *

What are they used for? Distance
Computer
Reading
*

Do you currently wear contact lenses? Yes No *

I would like to receive contact lens services from Dr. Murray. I understand that contact lens fitting fees are separate and in addition to routine eye examination fees and are non-refundable once initiated.

Please list any personal health conditions not listed above (1200 chars left)

Long Term Drug Use

Please check all of the following that apply to you Steroids
Non-steroidal anti-inflammatory drugs (NSAIDS)
Antiplatelets/Antithrombotic Medications

Are you currently taking any prescription or non-prescription medications? Yes No *

Please list all medications you are currently taking (1200 chars left) *

Do you have any allergies (medications, environment, etc.)? Yes No *

Please list all your allergies (1200 chars left) *

Pupil Dilation

Pupil dilation is part of a thorough eye examination. Pupil dilation is accomplished by putting a drop in each eye which will temporarily enlarge the pupils. Pupil dilation allows the doctor to get a more thorough look inside your eyes.

Pupil dilation is not uncomfortable, however, the drops take approximately 20 minutes to work and you may experience increased light sensitivity and blurred vision for several hours following pupil dilation.

Annual dilated eye examinations are highly recommended and there are no additional charges. Although highly recommended, some patients choose not to have their pupils dilated or reschedule dilation for another day. Please check the appropriate box below.

Will you have your pupils dilated on the day of your appointment? Yes, I agree to have my pupils dilated today
No, I understand the benefits of pupil dilation and choose not to have the procedure done today
*

Signature of Patient or Responsible Party (if patient is a minor) *

Date

What is 2 x 2 x 3? *

Online Patient Registration Submitted

Your online patient registration form has been submitted successfully. Thank you for your business; we look forward to seeing you at your appointment.