CAMBRIDGE EYE GROUP PATIENT REGISTRATION FORM
 (TO BE COMPLETED ONLINE BEFORE VISIT):

    Patient information:

    MEDICAL HISTORY

    FAMILY HISTORY

    SOCIAL HISTORY

    REVIEW OF SYSTEMS

    Constitutional:

    Integumentary:

    Neurological:

    Eyes:

    Endocrine:

    Ears, Nose,
    ​Mouth, Throat:

    Respiratory:

    Vascular/
    ​Cardiovascular:

    Gastrointestinal:

    Genitourinary:

    Bones/Joints/
    ​Muscles: 

    Lymphatic/
    ​Hematologic:

    Allergic/Immunologic:

    Psychiatric:

    Specialty Clinic or Services Section (OPTIONAL: please skip to bottom to submit form if you are not seeking specialty care)

    Dry Eye Clinic.
    Dry Eye Disease is the most frequent reason the patients visit eye doctors. We are concerned that you may be suffering with this condition as well. Therefore, we ask that you take a few moments and thoughtfully complete the questions below. 

    Report the FREQUENCY of the dry eye symptoms. How many times are you experiencing the symptoms?

    Report the SEVERITY of the dry eye symptoms

    Myopia Control Clinic
    Nearsightedness (myopia) is a common vision condition diagnosed during a basic eye exam. For those who are nearsighted, objects that are farther away appear blurry. Myopia is caused by genetics, as well as other environmental factors. For instance, staring at any object for too long can cause the eye to elongate — it’s this elongation that leads to myopia.

    Vision Reabilitation, Trauma, and Low vision Center
    There are many ways to help so that people with lost visual function or low vision can continue to do things that are important to them. Losing vision or visual function does not mean giving up activities, but it may mean learning new ways to do them.
    Vision rehabilitation will help retrain your eyes to regain meaningful and functional use.  We will help patients learn new strategies and find devices that can assist them.

Hours Of operations

Monday: 10:00 am to 6:00 pm
Tuesday: 10:00 am to 6:00 pm
Wednesday: 10:00 am to 6:00 pm
Thursday: 10:00 am to 7:00 pm
Friday: 10:00 am to 6:00 pm
Saturday: 10:00 am to 6:00 pm

Locations

Cambridge:
603 Concord Ave, STE B
Cambridge, MA
​02138
Phone: 617-945-2906​

​
​​Belmont: 
354 Pleasant Street, 
Belmont, MA, 
02478
Phone: 617-993-3565
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