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*
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Please provide a telephone number, with area code, so we can contact you.
Daytime Phone
Cell Phone
Email Address
Please provide us your email address.
Personal Information
Gender*
- Female
- Male
Date of Birth*
MM slash DD slash YYYY
Social Security Number (last 4 digits only!)
Preferred Language*
Race*
Ethnicity*
Marital Status
Marital Status - Other
Please provide your marital status.
Employment Status
Employment Status - Other
Please provide your employment status.
Employer
Occupation
How were you referred to our office?
Referral Status - Other
Please let us know how you were referred to our office.
Communication Preference
Eye History
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
I stopped wearing glasses because:
I stopped wearing contact lenses because:
Glasses History
Do you wear glasses?*
- Yes
- No
What glasses do you own?
- Single Vision
- Bifocals
- Safety Glasses
- Backup Glasses
- Progressive
- Trifocals
- Sports Glasses
- Sunglasses
- Other
Other glasses:
Please tell us what other kinds of glasses you own.
How many hours a day do you use a computer?
Please enter a number from 0 to 24.
How many inches away, approximately, do you sit from your computer monitor?
Please enter a number from 0 to 120.
Please check off any current conditions you suffer from
- I am having problems with my current glasses
- There are times when I would rather not be wearing glasses
- I have problems with glare
- I have problems with night vision
- I am allergic to nickel (e.g. frames of glasses)
- I don’t have spare set of glasses
- My spare glasses have an incorrect prescription
- My sunglasses are missing UV (ultra-violet) protection
Contact Lens History
Do you wear contact lenses?*
- Yes
- No
What brand of contact lenses do you wear?
How old are your current lenses?
How often do you replace or dispose your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule? In hours per day:
Please enter a number from 0 to 24.
What is your typical wearing schedule? In days per week:
Please enter a number from 0 to 7.
Please check off all that apply to you
- I am having problems with my current contact lenses
- There are times when I would rather not be wearing contact lenses
- I am interested in changing or enhancing my eye color
- I am interested in a non-surgical method of vision correction
- I am interested in refractive laser surgery
- I don't have a spare set of contact lenses
- My spare contact lenses have an incorrect prescription
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.)
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
Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Comments
If you have any comments you would like to add, please enter them here.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

21 hours ago

Super friendly people and great service! Dr. Starkey was great! So thorough!

- Aleysa G.

a day ago

Dr. Starkey and her staff are pleasant, kind and knowledgeable. I always leave with my questions answered and feeling valued as a patient.

- Angie M.

2 days ago

A +. Great experience as always. Been a patient here for 15 years and very happy with the care and service. Thank you.

- Heather W.

5 days ago

I had a great experience at Parenti-Morris, Amazing staff, very friendly and explained everything in detail. Sydney was so helpful and knowledgeable during my contact lenses fitting and I felt very comfortable getting my contacts in and out by the time I left. Highly recommend!

- Bryan K.

5 days ago

I absolutely love Dr Hines so much. she’s my go to lady and will always help with any eye issues or concerns i have.

- Madison T.

a week ago

Just like always amazing friendly staff and service

- Joseph S.

a week ago

Great service and punctuality. Friendly doctors and staff.

- Mom j.

16 hours ago

Outstanding experience! Everyone was so engaged with u! Loved it!

- John K.

17 hours ago

I was able to get in same day to be seen for a cut on my child’s eye. The staff was engaging and the doctor was well versed on how to get a toddler to cooperate during an exam. Really appreciate the experience and care!

- Haley S.

2 days ago

love Parenti Morris- Dr. Bell is very good and takes time with you , Staff is amazing . Steph did a great job helping me pick out glasses

- Carrie S.

2 days ago

Staff friendly. Dr. Bell was caring, attentive to my needs

- Elizabeth H.

a week ago

Had a wonderful check up, Dr Hines and staff were friendly, professional and took great care of me. 100% recommend going here to everyone I meet looking for an eye doc.

- Richard O.

Patient Registration Form

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Privacy Policy

Event and Team Highlights

Hear from Those Who Trust Us with Their Vision

Convenient Locations to Serve You

Parenti-Morris Eyecare – Bentonville

Parenti-Morris Eyecare – Rogers

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Privacy Policy

Event and Team Highlights

Hear from Those Who Trust Us with Their Vision

Convenient Locations to Serve You

Parenti-Morris Eyecare – Bentonville

Parenti-Morris Eyecare – Rogers

Call a Location

Find Out if Neurolens is Right for You, Take Our Short Questionnaire