NEC@nostalgiceyecare.com

Nostalgic Eye Care...An eye care experience that will last a lifetime!

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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

First Name

Email

Last Name

Phone Number

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Country

Race

Birthday

Employment Status

Occupation

Marital Status

Employer

How were you referred to our office?

Communication Preferance

Gender

Female

Male

Social Security Number (last 4 digits only!)

Eye History

Eye History

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

Fluctuation Vision

Loss of Vision

Loss of Side Vision

Glasses History

Glasses History

Yes

No

Contact Lens History

Contact Lens History

Yes

No

Medical History

When, approximately, was your last eye exam?

When, approximately, was your last physical exam?

Do you drink alcohol?

Where did you get your last eye exam?

Who is your primary care physician?

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

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)

Primary Insurance

Insurance Company Name

Insurance Company Number

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Wellness Fundus Photo: Wellness photo of your retina will allow the Doctor to have an image to compare the health of your retina and optic nerve over the course of the time. Wellness photos are not covered by insurance and will be a fee of $39.

Yes

No

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Personal Information

Contact Us

6656 Germantown Ave Suite 1

Philadelphia, PA, 19119

Phone: 215-842-5939

Fax: 215-842-5937

NEC@nostalgiceyecare.com

Office Hours

Monday: 9am - 5pm

Tuesday: 11am - 7pm

Wednesday: 9am - 5pm

Thursday: 11am - 7pm

Friday: 9am - 3pm

Saturday: Closed

Sunday: Closed

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