Cardinal Rosales Ave.,
Cebu City, Cebu 6000 Philippines

BOOK NOW

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Patient Center
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Online Store
About Us
Frames
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Contact Us
Appointment Request
Vision Topics
VASR by Vmax Vision Technology
App Portal

Home
Patient Center
Services
Online Store
About Us
Frames
Testimonials
Contact Us
Appointment Request
Vision Topics
VASR by Vmax Vision Technology
App Portal

BOOK NOW

Address
.,
.,
., . . .

Phone
(032) 415 1052

Home

Patient Center

New Patient Health History Form

New Patient Health History Form

NEW PATIENT REGISTRATION

In order to provide you the best possible care, please complete this form and bring it to your appointment. All information is strictly CONFIDENTIAL.

Contact Information

First Name / Last Name

Daytime Phone

Mobile Phone

Street Address

Bgy. / City / Zip Code

Guardian Information

First Name / Last Name

Daytime Phone

Mobile Phone

Street Address

Bgy. / City / Zip Code

Patient Information

Gender

Date of Birth

Patient History

Vision Correction History (please check any that apply)

Amblyopia (lazy eye) Blurred vision at a distance Blurred vision at near Burning Double vision Drooping eyelid(s) Dryness Eye pain and/or soreness Floaters or spots Fluctuating vision Foreign body sensation Halos I experience regular headaches I stopped wearing contact lenses I stopped wearing glasses Infection of eye or lid Itching Loss of peripheral vision Loss of vision Mucous discharge Redness Sandy or gritty feeling Sensitivity to light/glare Strabismus (crossed eye) Tired eyes Watery eyes

Glasses History

What glasses do you own?

Backup pair Bifocals Distance Progressive lens Reading Safety glasses Single vision Sports glasses Sunglasses Trifocals Others

If Other

How many hours per day do you spend using a computer?

Check any that apply

Custom Field

Allergic to nickel (frames) I do not want to wear glasses Incorrect prescription Need spare glasses Need sunglasses with UV Problems with current glasses Problems with glare Problems with night vision

Contact Lens History

What brand of contacts do you wear?

How old are your current contacts?

How often do you replace them?

What solution do you use for soaking?

What is your typical wearing schedule?

Check any that apply

I do not want to wear contacts Incorrect prescription Interested in non-surgical correction Interested in refractive laser surgery Need spare contacts Problems with current contacts Would like to change my eye color

Family History

(check all that apply)

Blindness Diabetes Eye turn/lazy eye Glaucoma Hypertension Macular degeneration None

Custom Field

General Medical History

When (approx.) was your last eye exam?

Primary care physician name

Primary care physician phone

Please list all eye conditions you have experienced:

Surgeries:

Do you have any of the following?

Arthritis Asthma Cancer Diabetes Heart disease High cholesterol HIV Hypertension (high blood pressure) Migraines/headaches Multiple sclerosis (MS)

Other:

Referral Information

Why did you visit us?

Referred by your doctor Visited our website Found us on social media Referred directly

Keep in touch

Facebook/Email

@Twitter handle

Questions and notes

Do you have a question? Concern? We want to know.

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Locations

Find us on the map

--mi

Level 2, Ayala Center Cebu

Address

Cardinal Rosales Ave.
Cebu City, Cebu 6000, Philippines

Contact Information

-- mi Level 2, Ayala Center Cebu
-- mi Ground Level, UC Banilad Bldg.
-- mi Ground Level, SM City Consolacion
-- mi Suite 2, UCMed

Hours of Operation

Our Regular Schedule

Ayala Center Cebu & SM City Consolacion

Monday

10:00 am - 9:00 pm

Tuesday

10:00 am - 9:00 pm

Wednesday

10:00 am - 9:00 pm

Thursday

10:00 am - 9:00 pm

Friday

10:00 am - 9:00 pm

Saturday

10:00 am - 9:00 pm

Sunday

10:00 am - 9:00 pm

UC Banilad - Taking appointments due to COVID 19

Monday

9:00 am - 6:00 pm

Tuesday

9:00 am - 6:00 pm

Wednesday

9:00 am - 6:00 pm

Thursday

9:00 am - 6:00 pm

Friday

9:00 am - 6:00 pm

Saturday

9:00 am - 6:00 pm

Sunday

Closed

University of Cebu Medical Center - UCMed

Monday

9:00 am - 12:00 pm

Tuesday

9:00 am - 12:00 pm

Wednesday

9:00 am - 12:00 pm

Thursday

9:00 am - 12:00 pm

Friday

9:00 am - 12:00 pm

Saturday

9:00 am - 12:00 pm

Sunday

Closed

(032) 415 1052

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