Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

*This field is required

Apt/Suite #

City

*This field is required

State

*This field is required

Zip Code

*This field is required

Cell Phone

*This field is required

Home Phone

*This field is required

Preferred Contact Method

Birthday

*This field is required

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Authorized people to release medical info to

Emergency Contact

Billing information

Is The Billing Address Different? Yes

please select this if the patient is a minor

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Medical Insurance

Please select your current Medical Insurance. If you do not see your insurance on this list, please contact our office prior to your appointment to verify if we accept it.

Insurance Information

Insurance Name:

If you have an HMO plan, you may be required to have a referral to be seen at our office. Please verify this with your insurance. If it is a requirement, one must be obtained PRIOR to your appointment. Please see our insurance policy form for more information.

Insurance Plan:

Insurance ID:

Insurance Policy Group:

If you are not the Primary Insurance Policy holder, you must fill in the fields below to continue.

Not Primary On Account: Not Primary

Name:

*This field is required

Relationship To Insured:

Spouse Child Other

*This field is required

Sex:

Male Female

*This field is required

Address:

*This field is required

City:

*This field is required

State:

*This field is required

Zip Code:

*This field is required

Phone Number:

*This field is required

Birthday:

*This field is required

SSN:

*This field is required

Employer/School:

*This field is required

Please choose from the menu options or select the option to type in your own text. Thank you!

Eye History

What is the main reason for your visit today?

Do you currently have any of these symptoms?

Do you currently take any of these eye medications?

Please list any eye surgeries and/or trauma (include dates)

Last Eye Exam

By Doctor

Ophthalmologist

Last Visit

Primary Vision Correction

What type of glasses do you wear?

How old are your glasses?

Do you wear contacts?

*This field is required

Contact Lens Wearers Only

Current CL wearer

Cleaner

Wear Time

Type of CLs worn in past

Sleep in CL

Disposal

Family Eye History

Does anyone in your family have any of these eye conditions?

Unknown family eye history

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Medical History:

Medications No Medications

Drug Allergies No known drug allergies

Vitamins

Over the Counter Medications

Please describe any injuries or surgeries you have had:

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Do you have any of these medical conditions?

Diabetes

Year Diabetes Diagnosed

HbA1c

High Blood Pressure

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Other

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

STDs