Online Patient Registration Form

Online 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.

COVID-19 Information

Have you or anyone in your home experienced a fever in the last 14 days?
Have you traveled outside of our area in the last 14 days? If yes, where

Patient Information

Personal Information

Gender*
Preferred Language*
Race*
Ethnicity*
Marital Status
Employment Status
How were you referred to our office?
Communication Preference

Eye History

Please check off any current conditions you suffer from

Glasses History

Do you wear glasses?*

Contact Lens History

Do you wear contact lenses?*

Medical History

Do you drink alcohol?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had
Please list all prescription and over-the-counter medications you take and for what conditions here or upload your file below
Please list all drug allergies you have
Please check off any current conditions you suffer from
Do you have seasonal allergies?

Medical Insurance

Please bring all insurance cards with you to your appointment.

Vision Insurance

Please bring all insurance cards with you to your appointment.

Comments

Privacy Policy

Health Information Protection*

Privacy Policy

Contact Info

  • Address:
    831 Vermont Street
    Lawrence, KS 66044
    Get Directions
  • Phone:
    (785) 843-5665
  • Fax:
    (785) 841-3153
Connect:
admin none 8:00 AM - 5:30 PM 8:00 AM - 5:30 PM 8:00 AM - 5:30 PM 8:00 AM - 7:00 PM 8:00 AM - 5:00 PM 8:00 AM - 12:00 PM Closed optometrist # # #