Patient Registration & Medical Questionnaire
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All items in red are required
Legal Name:    Date Of Birth:
Preferred Name:    Home Phone:
Work Phone:    Address:
Cell Phone:    City:
Employer:    State:
Social Security Number:    Zip Code:
Occupation:    Email:
For all Mutli-option select boxes below please press and hold the control key and use the mouse to select more than one option (Mac/Apple users will need to use the Command key)
Reason(s) for visit:
What were the main reasons you chose to schedule your visit with our office?
(select all that apply)
Special Vision Demands
Which of the following vision problems have you recently noticed
(select all that apply)
Which eye problem(s) are you concerned about or had a doctor's diagnosis?
select all that apply
Please list any allergies to medications:  List major injuries:
Are you pregnant:  Primary physician:
Do you smoke?
Please note any immediate family history of significant eye disease.
select all that apply

Payment Information:
Please enter your initials,
this constitutes an electronic signature:

By submitting this form I acknowledge all information above is accurate to the best of my knowledge
and that I agree with the Privacy Policy

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I have been a patient of Dr. Paul Naftali for about 10 years. Dr. Naftali has always treated me with the utmost respect and professionalism. He always does a wonderful job of explaining the results of my eye exams as well as answering any questions I may have. Dr. Naftali’s staff is also so friendly! They always greet me with a big hello and warm smile!!

Eric Rauschenberger

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