Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname	Pronoun
Mr. Mrs. Ms. Dr. Rev.						he/him/his she/her/hers they/them/theirs

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Cell Phone:
Home Phone:
Work Phone:
Last 4 numbers of SSN		Email
Date of Birth
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Married Not Married	Employer / School Name
Guardian

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Billing Information

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

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Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Medical History

Referred By:

Friend/Family Previous Walk In Insurance Advertisement Internet Other

Last eye doctor (if not with us):

Last eye exam (if not with us):

Never 1 year or less 1-2 years 3 years or more

Date of last physical exam with a primary care physician:

1 year or less 1-2 years 2 years or more Other

Name of primary care physician:

What is your occupation?:

Please list any diagnosed medical conditions such as hypertension, diabetes, or cancer as well as any surgeries or hospitalizations

Please list any diagnosed eye diseases such as glaucoma, cataracts, macular degeneration, uveitis, or retinal detachment

Please list any medications you are currently taking (or any new medications if you are an existing patient)

Are you allergic to any medications?

Please list any family history of diagnosed medical conditions such as hypertension, diabetes, or cancer

Please list any family history of eye diseases such as glaucoma, cataracts, macular degeneration, uveitis, or retinal detachment

Pregnant/Nursing:

Yes No N/A

Please list any history of eye surgery

Do you smoke?

No Former Occasional Everyday

Do you drink alcohol?

No Social Daily

Please list any history of eye injury

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