Accepted Insurance Plans

  • VSP
  • Eyemed
  • Blue Cross Blue Shield
  • HFS
  • Aetna
  • Superior Vision
  • Humana
  • Spectera
  • Optum
  • Unicare
  • Medicare
  • And more - Call to find out
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    Home Our Services New Patient Registration

    New Patient Registration Form
       
    Name:
    		  
    Address:  
    Phone Number:
    		  
    Email:
    		  
    Date of Birth:  
         
    Exam Type:  
    Appointment Date & Time Requested:  
    Insurance Type (if any):  
     
     

    Patient Medical History
       
    Allergies:
    		  
    Medications:
    		  
    Ocular History:
    		  
    Injuries / Surgeries:
    		  
       
         
    Primary Care Physician:  
    Physician Phone:  
         
    Pregnant  
         
    Wears Soft Contacts Wears Hard Contacts


    Contacts are Comfortable  
       
    Wears Glasses  
     
    Family Medical History: Check the conditions that apply, and list the relation to yourself (i.e. Maternal Grandmother, Father, etc.)
       
    Blindness
    Cataracts
    Cancer
    Diabetes
    Heart Disease
    		 Retinal Detachment
    Crossed Eyes
    Lupus Macular Degeneration
    Glaucoma
    		 High Blood Pressure
    Kidney Disease
    Arthritis
    Thyroid Disease
       
    Social History
       
    Drives
    Uses Tobacco
    Drinks Alcohol
    Use Illegal Drugs Type/Amt/Length:
       
    Have you ever been exposed to or infected with: Gonhorrhea Syphilis
    Hepatitis HIV
       
    Review of Systems. Please check all that apply to you.
       
    Eyes
    Gastrointestinal
    Constitutional
    Vision Loss
    		 Colitis
    		 Fever
    Blurry Vision Crohn's Disease Weight Loss/Gain
    Distorted Vision Ulcers Fatigue
    Double Vision Constipation Trauma
    Dryness Diarrhea  
    Redness    
    Mucous Discharge Endochrine Respiratory
    Gritty Feeling Non Insul. Diabetes Asthma
    Itching Insul. Diabetes Bronchitis
    Burning Thyroid Dysfunction Emphysema
    Excess Watering Hormonal Dysfunction  
    Light Sensitivity    
    Eye Pain/Soreness Neurologic Allergic/Immune
    Chronic Infection Headaches Drug Allergies
    Sties Migraines Seasonal Allergies
    Flashes Seizures Lupus
    Floating Spots Mult. Sclerosis Arthritis
    Tired Eyes

    		   
         
    Ears/Nose/Throat
    Genitourinary
    Musculoskeletal
    Allergies Kidney Problems Fibromyalgia
    Sinus Congestion Bladder Problems Muscular Dystrophy
    Runny Nose STD's Osteoarthritis
    Post Nasal Drip   Ankylosing Spond.
    Chronic Cough    
    Dry Throat/Mouth    
         
    Integumentary (Skin)
    Cardiovascular
    Lymphatic/Hematologic
    Eczema
    		 Heart Disease Anemia
    Rosacea Hypertension Bleeding Problems
    Psoriasis   Leukemia
         
    Other
     
     
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    Reach out to Eye Society today to make a difference

    Please contact Eye Society today to discuss eyecare and eyewear needs. Glasses are more than just crafted work of plastic, metal, and science; it is a representation of your personality, fashion, and outer reflection of your inner artist. We're just here to help you find the right piece.

    24 Hour Emergency Service: Eye Society understands the importance of immediate eye care in certain situations. If you experience any of the symptoms below, it may be serious; please call the Eye Society office for an immediate evaluation or consultation at (312) 640-2405.

    Symptoms include: sudden vision loss, pain, light sensitivity, discharge, redness, flashes of light, or floaters.

    Eye Society. Providing the ultimate eyecare experience.

    Contact EyeSociety

    230 East Ohio Street, Suite #120
    Chicago, IL 60611 USA

    Phone:  (312) 640-2405
    Fax No:     (312) 640-6017
    E-mail:  info@eyesoc.com

    Normal Business Hours

    Monday-Friday:    10am - 7pm

    Saturday:             10am - 3pm

    Sunday:               Closed

     

    Appointments may be made outside normal business hours.



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