Patient Forms

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:
City:		State/ZipCode

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer / School Name
Misc/Guardian

Is the Billing Address Different?

Insurance Information

Not Primary on Account

Primary on Account

Insurance Information

Not Primary on Account

Primary on Account

Insurance Information

Not Primary on Account

Primary on Account

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Who referred you to our office?:

Were you referred by another doctor? If so, who?:
Who in your family also comes to Alabaster Eye Care?:

Please list any hobbies you have:

Are you interested in contact lenses?:
Have you ever worn contact lenses?

What type of contact lenses have you worn in the past?:
Do you have back up glasses for your contact lenses?:

What is you primary vision correction?:
Do you wear prescription sunglasses?:

Are you interested in Laser Vision Correction?:

Eye History: Do you have a history of any of the following?:

Do you currently use any eye medications?:

Who was your last eye doctor?:
Who is your primary care doctor?:

Please list any other prescription/otc medication you are currently taking:

Please list any medical conditions you currently have:

Family Medical History:
Family Eye History:

Do you have any medication and/or seasonal allergies?:

Alcohol, Tobacco, and Drug Use: