Online Forms

Online Forms

Online Forms

Online Forms

Online Forms

We Are Very Pleased To Welcome You To Our Office.


Your Appointment Time Is Reserved For You. Please If You Must Reschedule We Ask For A Minimum Of 24-­‐hour Cancellation Notice So We Could Accommodate Other Patients.

For your convenience, you can also download the Patient Registration Form and bring it with you on your next appointment.

Download Now


​​​​​​​Please Fill This Registration Form Ahead Of Your Initial Visit:

Patient Information and Medical History Form

If you have any questions, please call us at (310) 452-1039 or email us at info@opoptometry.com. We can always change the data in the office if you are unsure about what to enter in any of the fields.

Mailing Address / City / State / Zip Code
Social Security Number:
Date of Birth:
Gender
Height
Weight
Telephone Number:
May We Leave Personal Medical Information On Your Email?
May We Leave Personalmedical Information With Texts?
May We Leave Personal Medical Information On Your Voicemail?
How Did You Hear About Us?
What Is The Reason For Today’s Visit?

Areas of Interest: (mark all that apply)

Facial Procedures

Areas of Interest: (mark all that apply)

Laser and Aesthetic Skin Care Procedures

Areas of Interest: (mark all that apply)

Breast Procedures

Areas of Interest: (mark all that apply)

Body Procedures

IF PATIENT IS UNDER AGE OF 18
Parent / Guardian Name
Contact Number
Additional Authorized Contact (Full name and Relationship)
Contact Number
PHYSICIAN INFORMATION
Primary Care Physician
Contact Number
Other Physician
Specialty
Contact Number
Other Physician
Specialty
Contact Number
PHARMACY INFORMATION
Pharmacy Name
Pharmacy Address
Pharmacy Number
ALLERGIES (Please list all medical allergies)
Do You Have A Latex Allergy?
MEDICATIONS

Are You Currently Taking Any Medication? List Any Medications You Are Currently Taking Such As Blood Thinners, Vitamins, Natural Herbs Or Diet Supplements.

Please list any additional medications

HISTORY
Do you smoke any tobacco at all, even occasionally?
Do you use recreational drugs?
Do you drink alcohol?
Do you have a pain management physician?
Ethnicity
Race
Do you have any medical problems?

Please list any aditional problems

Please list all surgeries, hospitalization and date of occurence

Please list all any cosmetic procedures or surgeries you have had / chemical peels / lasers. Include dates.

Do you have or have you had any of the following: (Give date occured if Yes)

AIDS/HIV
Date
ARTHRITIS
Date
ASTHMA
Date
BRONCHITIS
Date
CANCER
Date
DEPRESSION
Date
DIABETES
Date
DIZZINESS/VERTIGO
Date
EAR INFECTION
Date
EPILEPSY/SEIZURES
Date
FACIAL PAIN
Date
FEVER BLISTERS
Date
GOITER/THYROID
Date
HAY FEVER/ALLERGIES
Date
HEADACHES/MIGRAINE
Date
HEART TROUBLE
Date
HEPATITIS
Date
PNEUMONIA
Date
STROKE
Date
TONSILLITIS
Date
TUBERCULOSIS
Date
ULCERS
Date
WEIGHT GAIN/LOSS
Date
SINUS PROBLEMS
Date