Please print and fill out these forms,
then bring them with you when you visit us.
Microsoft Word
Registration Form
Medical History Form
Adobe Acrobat
Registration Form

Medical History Form

Your First Visit

To enable Dr. Elmquist and our staff to best meet your particular eye care needs, we ask that you complete our registration and health history forms. A list of your current medications and dosages as well as any previous eye care records will also be helpful.

Please remember to bring your glasses to each appointment. This information will help in diagnosing the most common conditions like myopia and astigmatism, as well as complex conditions such as glaucoma and macular degeneration.

Please complete the registration form and the medical history form provided here in Adobe Acrobat format and to the left in both Microsoft Word and Adobe Acrobat format. With the Adobe Acrobat version you can either print and complete by hand or fill out the forms online, then print. Whichever you choose, please sign and bring them with you when you visit us.

Elmquist Eye Group of Southwest Florida
12670 New Brittany Blvd., Suite 102
Fort Myers, Florida 33907

Phone: (239) 936-2020
Copyright © 2007 Coconet Corporation. All rights reserved.