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Hours & Locations
About Us
- Our Eye Doctors
- The Staff
Eye Care Services
Eyeglasses & Contacts
- Oconomowoc Vision Clinic Warranty, Exchanges and Return Policy
Promotions & Events
Insurance

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Schedule An Appointment

Oconomowoc
262-233-2992

Watertown
920-390-2971

Waukesha
262-233-2325

Home » Online Patient Paperwork » Patient Registration Form

Patient Registration Form

Patient Registration Form

Consent to Treat*
By signing this form, I consent to treatment for myself and/or on behalf of the Minor for which this information pertains. I give permission for the doctor/s to examine, diagnose and initiate treatment as deemed appropriate. I further attest that I am the Parent or Legal Guardian of Minor and have the authority to authorize care and treatment.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Patient Information
Name*
First Last
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.
Cell Phone
Email Address
Which Office?*
- Watertown Vision
- Oconomowoc Vision
- Waukesha Eye and Vision
Personal Information
Gender*
- Female
- Male
Date of Birth*
Month
Day
Year
Social Security Number
Preferred Language*
Race*
Ethnicity*
How were you referred to our office?
Referral Status - Other
Please let us know how you were 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 because:
I stopped wearing contact lenses because:
Glasses History
Do you wear glasses?*
- Yes
- No
Please check off any current conditions you suffer from
- I am having problems with my current glasses
- I have problems with glare
- I have problems with night vision
Contact Lens History
Do you wear contact lenses?*
- Yes
- No
What brand of contact lenses do you wear?
Please check off all that apply to you
- I am having problems with my current contact lenses
- I am interested in a non-surgical method of vision correction
- I am interested in refractive laser surgery
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?
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 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
Insurance
Do you have insurance?*
- Yes, I do
- No, I do not have insurance and will be paying for the exam/appointment myself.
Medical Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name*
Insured's Name*
First Last
Identification Number*
Group Number
Insured's Date of Birth*
MM slash DD slash YYYY
Patient's Relation to Insured*
Do you have secondary insurance?
- Yes
- No
Primary Vision Insurance
Insurance Company Name*
Insured Name*
First Last
Identification Number*
Insured Date of Birth*
MM slash DD slash YYYY
Patients Relations Insured*
Secondary Insurance
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
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.
Phone
This field is for validation purposes and should be left unchanged.

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Follow Us

Oconomowoc Vision Clinic

1674 Old School House Rd., Suite 101
Oconomowoc, WI 53066

Email: oconomowocvisionclinic@rocketmail.com
(Do not send personal health information by email.)
Phone: 262-567-2295

Monday: 8:00 AM - 5:30 PM
Tuesday: 8:00 AM - 2:00 PM
Wednesday: 8:00 AM - 5:30 PM
Thursday: 8:00 AM - 5:30 PM
Friday: 8:00 AM - 2:00 PM
Saturday: Closed, emergency services only
Sunday: Closed, emergency services only

Waukesha Eye and Vision

1111 Delafield St. Suite 212
Waukesha, WI 53188

Email: wevcappointments@gmail.com
(Do not send personal health information by email.)
Phone: 262-521-9383

Monday: 8:00 AM - 5:30 PM
Tuesday: 8:00 AM - 2:00 PM
Wednesday: 8:00 AM - 5:30 PM
Thursday: 8:00 AM - 5:30 PM
Friday: 8:00 AM - 2:00 PM
Saturday: 8:30 AM - 1:00 PM, the second Saturday of each month
Sunday: Closed

Watertown Vision

1640 S Church St, Ste 100
Watertown, WI 53094

Email: watertownvision@gmail.com
(Do not send personal health information by email.)
Phone: 920-390-2971

Monday: 9:00 AM - 7:00 PM
Tuesday: 9:00 AM - 7:00 PM
Wednesday: 9:00 AM - 2:00 PM
Thursday: 9:00 AM - 5:00 PM
Friday: 8:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

Find Us Here

Waukesha Eye and Vision - Located at 1111 Delafield St. Suite 212, Waukesha, WI 53188. Phone: 262-521-9383. https://www.oconomowocvisionclinic.com

Watertown Vision - Located at 1640 S Church St, Ste 100, Watertown, WI 53094. Phone: 920-390-2971. https://www.oconomowocvisionclinic.com

Oconomowoc Vision Clinic - Located at 1674 Old School House Rd., Suite 101, Oconomowoc, WI 53066. Phone: 262-567-2295. https://www.oconomowocvisionclinic.com

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