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.
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*
Date Format: MM slash DD slash YYYY
Social Security Number (last 4 digits only!)
Preferred Language*
Race*
Ethnicity*
Marital Status
Employment Status
Employer
Occupation
How were you 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
Glasses History
Do you wear glasses?*
- Yes
- No
Contact Lens History
Do you wear contact lenses?*
- Yes
- No
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
Date Format: MM slash DD slash YYYY
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
Comments
If you have any comments you would like to add, please enter them here.
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Health Information Protection*
I have read and agree to the Privacy Policy

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Testimonials

Clinton
Lee’s Summit
Sedalia
Warrensburg

Clinton
Lee’s Summit
Sedalia
Warrensburg

first rate

Caring and prompt, the service is always first rate.
Patient in Warrensburg MO

I wish all doctors were modeled after him

I see Dr. Kyle Johnson and he is awesome. He takes the time to answer all of my questions and concerns and I believe he truly cares. I have never seen him without a smile and kind, compassionate, positive attitude. I wish all doctors were modeled after him. You won’t be sorry, if you choose to see him. The office staff are all very polite, professional, and efficient.
Patient In Clinton, MO

I see a lot of doctors, but Dr.Susan is the only one I look forward to seeing each year

Everyone in the office is extremely nice. I am 72 yrs. old and a long time patient with only one good eye. I trust Dr. Susan Lake with the care of it 100%. Being 72, I see a lot of doctors, but Dr.Susan is the only one I look forward to seeing each year.
Patient in Warrensburg MO

I highly recommend them

I’ve been going to Dr. Liesemeyer for almost 25 years. His group offers personal and professional services I highly recommend them.
Patient In Sedalia, MO

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Clinton
Lee’s Summit
Sedalia
Warrensburg

Clinton
Lee’s Summit
Sedalia
Warrensburg

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Eyecare Specialties – Lee’s Summit – 1652 SE Blue Pkwy, Lee’s Summit, MO, 64063. Phone: (816) 598-4310.

Eyecare Specialties – Sedalia – 3403 W 10th St, Sedalia, MO, 65301. Phone: (660) 285-4180.

Eyecare Specialties – Warrensburg – 601 E Russell Ave Ste A, Warrensburg, MO, 64093. Phone: (660) 628-1836.

Eyecare Specialties – Clinton – 1104 E Ohio St., Clinton, MO, 64735. Phone: (660) 228-1135.

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Patient Registration Form

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Privacy Policy

first rate

I wish all doctors were modeled after him

I see a lot of doctors, but Dr.Susan is the only one I look forward to seeing each year

I highly recommend them