Dr. David Lelonek
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Patient Registration Form for Dr. David Lelonek

Please complete the information below and print out the completed form
and bring it with you when you come to our office. 


Date: 
Patient  Name:   Sex: M F  
E-mail Address:
Street Address: 
City, State, Zip: ,  
Date of Birth:       Phone No.
Marital Status: Single  Married  Divorced   Separated   Widowed
Referring Doctor:  
Address of Referring Doctor:  
Social Security Number:
Spouse or Nearest Relative:  
Phone No:    Relationship:
Person Responsible for Bill:
Address:
Employer:   Phone No:

INSURANCE INFORMATION
Primary Insurance Company:
Policy Holder:   Date of Birth:
Relationship to Patient:   SSN:
Mail Claims To: (Address)
Phone No:    Policy No:
Secondary Insurance Company:
Policy Holder:   Date of Birth:
Relationship to Patient:   SSN:
Mail Claims To: (Address)
Phone No:    Policy No:
Third Insurance Company:
Policy Holder:   Date of Birth:
Relationship to Patient:   SSN:
Mail Claims To: (Address)
Phone No:    Policy No:

EYEGLASS HISTORY
Do you wear glasses? Yes No Full Time Part Time Distance Near
Glasses owned: Single Vision Bifocals Safety Glasses Backup Glasses
. Progressive Trifocals Sports Glasses Other
Do you use a computer? Yes No Hours per day: Distance from computer:
Do you have problems with glare? Yes No
Do you have problems with night vision? Yes No
Are you allergic to Nickel (eg; jewelry or eyeglass frames discoloring your skin)? Yes No
If you currently wear eyeglasses, are there certain times when you would rather not? Yes No
If you currently wear eyeglasses, does your spare pair have your correct prescription? Yes No
Do your sunglasses have UV (ultra-violet) protection? Yes No
Are your sunglasses your current prescription? Yes No

MEDICAL HISTORY

With vision correction being used, do you suffer from any of the following?
Distance Vision Blur Yes No Seeing Flashes Yes No Dry Eyes Yes No
Near Vision Blur Yes No Distorted Vision (Haloes) Yes No Itching Yes No
Middle Vision Blur Yes No Glare/Light Sensitivity Yes No Red Eyes Yes No
Double Vision Yes No Loss of Side Vision Yes No Eye Pain/ Soreness Yes No
Headaches Yes No Crossed Eyes Yes No Mucous Discharge Yes No



For security reasons, please print this page out and bring it with you on your next visit.
Thank you for your time!



1250 Old Country Road
(Located within the Westbury Costco)
Westbury, New York 11590
Phone: (516) 222-6580
Fax: (516) 222-6297

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