Crystal Clear Vision Center Optometry, Inc.

Home
About
- Meet Our Optometrist
- Eye Health
Services
Eyeglasses & Contacts
Patient Information
Contact

Home
About
- Meet Our Optometrist
- Eye Health
Services
Eyeglasses & Contacts
Patient Information
Contact

BOOK AN APPOINTMENT

BOOK AN APPOINTMENT

Crystal Clear Vision Center Optometry, Inc.

Home
About
- Meet Our Optometrist
- Eye Health
Services
Eyeglasses & Contacts
Patient Information
Contact

Home
About
- Meet Our Optometrist
- Eye Health
Services
Eyeglasses & Contacts
Patient Information
Contact

BOOK AN APPOINTMENT

BOOK AN APPOINTMENT

Home | Patient Information | Patient Registration Form

Patient Registration Form

/ EXPERT EYE DOCTOR IN SAN FRANCISCO

Crystal Clear Vision Center Optometry Patient 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.

Prefix*

Name*

Last Name*

Address*

City*

State / Province / Region*

ZIP / Postal Code*

Country*

Phone*

Email*

Gender*

Date of Birth*

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

Please check off any current conditions you suffer from

I stopped wearing glasses

I stopped wearing contact lenses

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

Mucous Discharge

Drooping eyelid(s)

Redness

Sandy or Gritty Feeling

Strabismus (crossed eye)

Blurred Vision at Distance

Blurred Vision at Near

Haloes

Double Vision

Floaters or Spots

Fluctuating Vision

Loss of Vision

Loss of Side Vision

Do you wear glasses?*

Do you wear contact lenses?*

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?

Please list all medical conditions you have ever had

Please list all eye conditions you have ever had

Family Medical or Eye Conditions

Please list all hospital surgeries you have ever had

Prescription and Over-The-Counter Medications

Please list all drug allergies you have

Please check off any current conditions you suffer from

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)

Insurance Company Name

Insurance Company Phone Number

Address

City

State / Province / Region

ZIP / Postal Code

Country

Insured's First Name

Insured's Last Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Do you have secondary insurance?

Comments

Crystal Clear Vision Center Optometry, Inc.

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Visit us

781 Vallejo St.

San Francisco, CA 94133

CALL us

Phone: (415) 677-9930

Fax: (415) 677-9599

HOURS

Mon, Tue, Thu, Fri, Sat

9:00 am - 5:00 pm

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