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Demographics

General Information

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

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:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married	Employer/School Name
Primary Doctor	No Doctor Assigned	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

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:

Vision Insurance

Insurance Information

Insurance Name:	None Vision Service Plan (VSP) EyeMed Medical Eye Services (MES)
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Personal and Social History

Referred By: Friend/Family Co-Worker Yelp Website/Internet Insurance Walk-by/Drive-by Referring Doctor: Family Patients:
Please list all your Hobbies:
Ever Worn Contact Lenses? Yes No Type of CLs worn in past: Daily Disposables Extended Wear Gas Permeables Gas Perm Bifocals Monovision - Disposables Monovision - Gas Perm No CL Hx Soft Daily Wear Soft Torics Interested In Contact Lenses? Yes No
Primary Vision Correction: Glasses Progressives Bifocals Contacts Contacts - Mono None Trifocals Do you have Sunspecs? Yes No Do you have Computer Specs? Yes No
Interested in Laser Vision Correction? Not Interested Yes

Medical, Personal and Family History

Primary Care Physician: Last Eye Doctor:

Please select your current Eye Medications (if not listed please type in box below):

None	Acular	Artificial Tears	Betoptic-S 0.25%	Betoptic 0.5%	Betagan	Erythromycin	FML	FML Forte	Gentamicin
Neosporin	Ocupress	Pilo Gel	Propine	Polytrim	Pred Mild	Pred Forte	Patanol	Timoptic 0.25%	Timoptic 0.5%
Tobradex	Voltaren	Xalatan

Please select your current Eye History (if not listed please type in box below):

None	Abrasion	Blind Eye	Blepheroplasty	Cataract - Both Eyes	Catatract - Right Eye	Catatract - Left Eye
Conjunctivitis	Glaucoma	IOL-Both Eyes	IOL -Right Eye	IOL -Left Eye	Metal in Eye	Ptosis
Retinal Detachment	Weak Eye	Lazy Eye

Please list any Prescription Medications:


Please select your current Medical History (if not listed please type in box below):

None	HAs	Arthritis	Asthma	Diabetes
HIV+	Nursing	Seizures	Thyroid	High Blood Pressure	Smoke	Pregnant	Inflamed Bowel Disorder

Please select your Family Medical History (if not listed please type in box below):

None	Cancer	Diabetes I	Diabetes II	Hypertension
Thyroid	Heart Disease	Seizures	Hypercholesterolmia	High Blood Pressure

Please select your Family Eye History (if not listed please type in box below):

None	Abrasion	Blind Eye	Blepheroplasty	Cataract - Both Eyes	Catatract - Right Eye	Catatract - Left Eye
Conjunctivitis	Glaucoma	IOL-Both Eyes	IOL -Right Eye	IOL -Left Eye	Metal in Eye	Ptosis
Retinal Detachment	Weak Eye	Lazy Eye

Please list Medication and Seasonal Allergies:

NOTES/SOCIAL HISTORY

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