Coronado Eye Care Optometry
Call Us: (619) 435-6221
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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


Name *


Address *


Phone Number *


Daytime Phone
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Cell Phone
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Email Address
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Personal Information


Gender *


Date of Birth *
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Social Security Number (last 4 digits only!)
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Preferred Language *
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Race *


Ethnicity *


Marital Status


Employment Status


Employer


Occupation


How where you referred to our office?
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Communication Preference
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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


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 (Diabetes, High blood pressure, Arthritis, etc.)
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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

Primary Insurance

Please bring all insurance cards with you to your appointment.


Insurance Company Name


Insurance Company Phone Number


Address


Insured's Name


Identification Number


Group Number


Insured's Date of Birth


Patient's Relation to Insured
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Secondary Insurance


Do you have secondary insurance?
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Comments


If you have any comments you would like to add, please enter them here.
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Privacy Policy


Health Information Protection *
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