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.

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!)
Please enter a number from 0000 to 9999.
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
Special Needs
If other, please specify
Details
Local Pharmacy
Mail Order Pharmacy
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 bring a current list of all prescription medications to your appointment
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 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
Secondary Medical 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
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Primary Vision 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
Secondary Vision 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
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
Name
This field is for validation purposes and should be left unchanged.

"State of the art business, Very professional staff--from the eye exam through purchasing eyewear. I have been a patient since 2007"...

- Druane H. - Saginaw, MI

"I would highly recommend Associates in Eyecare. Very knowledgeable and attentive to the patients needs."...

- Jeff C. - Saginaw, MI

-"This was a very good experience for me. I was seen at the time that my appointment was set for, I didn't have to wait at all! Everyone was very professional and they made me feel like I was valued. To sum up this visit...They were prompt, professional, courteous and...

- Sheila L. - Saginaw, MI

"Dr. Kocks is The best, if your looking for a doctor that gives an excellent eye exam, he's the one, I am always satisfied with his work. God bless you and your staff." ...

- Dot W. - Saginaw, MI

"Great service and treatment as always! Thank you!" ...

- Sara H. - Saginaw, MI

"They are very friendly and helpful."...

- Kelly S. - Saginaw, MI

"A very welcoming experience. The staff is very friendly and the doctors seem very knowledgeable. I would recommend."...

- B. - Saginaw, MI

"Doctor Barden is WONDERFUL! Doctor Barden is great with children and adults. She listens and gives a very detailed eye exam. She explains each step in the process, so her patients feel relaxed and that they are in capable hands!" ...

- Barbara T. - Saginaw, MI

"Dr. Kaczmarczyk and her entire staff are very professional, knowledgeable and friendly. I would recommend everyone to get their vision cared for here."...

- Kenneth B. - Saginaw, MI

Friendly, knowledgeable, attentive, fast! I'm so glad I found them! After being dissatisfied with Walmart Vision and Americas Best, I knew I needed a better eye doctor. It makes an incredible difference in my life....

- Jamie S. - Saginaw, MI

I called the office this afternoon after my son tore his last pair of contacts. It's Friday afternoon and the office had just closed. Dr. Kocks went back to the office to get him an extra pair to get through the weekend. Above and beyond! Thank you so much!...

- Kristin V. - Saginaw, MI

Patient Registration Form

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Medical Insurance

Secondary Medical Insurance

Primary Vision Insurance

Secondary Vision Insurance

Comments

Privacy Policy

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