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Patient Registration Form

Patient Registration Form at Connecticut Retina Consultants

Contact us for more information. We have convenient locations to serve you in Hamden, Norwalk, Trumbull, New Haven, Madison, and Fairfield CT.

To Fill It Out Digitally Click Below

NEW PATIENT REGISTRATION FORM
PATIENT MEDICAL RECORDS RELEASE FORM

To Download, Complete and Print the Form at Home Click Below

NEW PATIENT REGISTRATION FORM
PATIENT MEDICAL RECORDS RELEASE FORM

On the day of your appointment, please bring the following with you:

  • Your photo ID
  • Current health insurance card(s)
  • A completed Patient Registration form (enclosed)
  • A completed Medical History form (enclosed)
  • If you wear eyeglasses please bring them to your appointment
  • A list of any medications, including dosage

Your eyes will be fully dilated to ensure a thorough retinal exam and may remain dilated for several hours afterward. For safety, we recommend that someone drive you home from each visit.