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419 East Main Street Burnsville, NC 28714

828-682-2104

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Insurance

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Our Eye Doctors
The Staff
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PATIENT REGISTRATION FORM

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Date

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Mailing Address

Street Address City State / Province / Region ZIP / Postal Code

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Age:

Birth Date:

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Social Security Number:

Race:

Language:

Ethnicity:

Occupation:

Employer:

Work#:

Emergency Contact:

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Phone #;

If minor, responsible party:

If completed by someone other than patient;

Signature

Relationship:

Primary Care Physician:

Preferred Pharmacy:

Reason for your visit today (be specific)?

Referred by:

Please review and check the following complaints you have:

Headaches

Blurred Vision (Far, Near or Both?)

Double Vision

Poor Depth Judgment

Eye Pain or Discomfort

Floaters/Flashes of Light

Other:

Do you CURRENTLY have any problems in the following areas? If YES, please provide information.

EARS, NOSE, THROAT (Sinus, Ear Infection, Chronic Cough, Dry Mouth, etc.)

Yes

No

EXPLANATION OF PROBLEM

CARDIOVASCULAR (Heart, Vessels, etc )

Yes

No

EXPLANATION OF PROBLEM

RESPIRATORY (Asthma, Emphysema, etc.)

Yes

No

EXPLANATION OF PROBLEM

GASTROINTESTINAL (Stomach Ulcers, Intestinal Disease, Hepatitis, etc.)

Yes

No

EXPLANATION OF PROBLEM

GENITAL, KIDNEY, BLADDER

Yes

No

EXPLANATION OF PROBLEM

MUSCLES, BONES, JOINTS (Arthritis. etc.)

Yes

No

EXPLANATION OF PROBLEM

SKIN (Acne, Warts, Skin Cancer, etc)

Yes

No

EXPLANATION OF PROBLEM

NEUROLOGICAL (Muttiple Sclerosis, etc.)

Yes

No

EXPLANATION OF PROBLEM

PSYCHIATRIC (Anxiety, Depression, Insomnia)

Yes

No

EXPLANATION OF PROBLEM

ENDOCRINE (Diabetes, Hypothyroid, etc.)

Yes

No

EXPLANATION OF PROBLEM

BLOOD/LYMPH (Cholesterolemia, Anemia, etc.)

Yes

No

EXPLANATION OF PROBLEM

ALLERGIC/IMMUNOLOGIC (Hay Fever, Lupus, Sjogens, HIV, Aids, seasonal allergies, etc)

Yes

No

EXPLANATION OF PROBLEM

GENERAL(Fever, Weight Loss, Other)

Yes

No

EXPLANATION OF PROBLEM

MEDICATIONS

List all medications that ypu currently take, including eye drops, over the counter medications, vitamins or supplements

How do you wish to pay for today's visit?

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Vision Insurance

Medical Insurance

(Please Present ALL Insurance Cards)

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Aldridge Eye in Burnsville

419 East Main Street
Burnsville, NC 28714

Email: aldridgeappts@gmail.com
(Do not send personal health information by email.)
Phone: 828-682-2104
Fax: 828-682-4217

Monday: 7:45 AM - 5:00 PM
Tuesday: 7:45 AM - 5:00 PM
Wednesday: 7:45 AM - 5:00 PM
Thursday: 7:45 AM - 5:00 PM
Friday: 7:45 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

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Aldridge Eye Institute - Located at 419 East Main Street, Burnsville, North Carolina 28714 Phone: 828-682-2104

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