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Optometrista en Chula Vista
- Exámenes Oculares Para Niños En Chula Vista
- Emergencias Oculares en Chula Vista, CA
Hours & Locations
- Eastlake Vision
- Clear Vision Optometry

About Us
- Our Eye Doctor
- Eye Care Professionals
Insurance
Eye Care Services
Designer Eyewear & Contacts Lenses
Optometrista en Chula Vista
- Exámenes Oculares Para Niños En Chula Vista
- Emergencias Oculares en Chula Vista, CA
Hours & Locations
- Eastlake Vision
- Clear Vision Optometry

Eastlake Vision

Clear Vision

In the McDonald’s and I-HOP shopping center in Eastlake

Next to Scripps Hospital between H Street and G Street.

Schedule an Appointment

Schedule an Appointment

Eastlake Vision
In the McDonald’s and I-HOP shopping center in Eastlake
619-831-6673

Clear Vision
Next to Scripps Hospital between H Street and G Street.
619-431-3944

About Us
- Our Eye Doctor
- Eye Care Professionals
Insurance
Eye Care Services
Designer Eyewear & Contacts Lenses
Optometrista en Chula Vista
- Exámenes Oculares Para Niños En Chula Vista
- Emergencias Oculares en Chula Vista, CA
Hours & Locations
- Eastlake Vision
- Clear Vision Optometry

About Us
- Our Eye Doctor
- Eye Care Professionals
Insurance
Eye Care Services
Designer Eyewear & Contacts Lenses
Optometrista en Chula Vista
- Exámenes Oculares Para Niños En Chula Vista
- Emergencias Oculares en Chula Vista, CA
Hours & Locations
- Eastlake Vision
- Clear Vision Optometry

Home » Contact Us » Online Patient Registration Form

Online 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.
Location
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*
Social Security Number (last 4 digits only!)
Please enter a value between 0000 and 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
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 value between 0 and 24.
How many inches away, approximately, do you sit from your computer monitor?
Please enter a value between 0 and 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 value between 0 and 24.
What is your typical wearing schedule? In days per week:
Please enter a value between 0 and 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
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
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
Comments
This field is for validation purposes and should be left unchanged.

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Clear Vision Appointment

Eastlake Appointment

Patient History Form

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Hours & Locations

Eastlake Vision

Welcome to Eastlake Vision Center Optometry, serving east Chula Vista including Eastlake, Rolling Hills Ranch, Otay Ranch, and San Miguel Ranch....

Eastlake Vision 2260 Otay Lakes Rd # 111
Chula Vista, CA 91915

Phone: 619-421-5550

Clear Vision Optometry

Dr. Efrain Mascareño's second location, Clear Vision Optometry, is located on 4th Avenue in Chula Vista, serving west Chula Vista, National City, and San Ysidro....

440 4th Ave
Chula Vista, CA 91910

Phone: 619-427-2020

Emergency: In case of emergency, please phone our office at the number listed above and follow the instructions.

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About Us
Insurance
Eye Care Services
Designer Eyewear & Contacts Lenses
Optometrista en Chula Vista
Hours & Locations

About Us
Insurance
Eye Care Services
Designer Eyewear & Contacts Lenses
Optometrista en Chula Vista
Hours & Locations

Home
Privacy Policy
Contact Us
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Disclaimer
Privacy Policy

Home
Privacy Policy
Contact Us
What’s New
Disclaimer
Privacy Policy

Eastlake Vision - Located at 2260 Otay Lakes Rd, Ste 111, Chula Vista, CA, 91915. Phone: 619-421-5550. https://www.eastlakevision.com/

Clear Vision Optometry - Located at 440 4th Avenue, Chula Vista, CA, 91910. Phone: 619-427-2020. https://www.eastlakevision.com/

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