Online Patient Form

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Demographics


Patient Information

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Cell Phone:
Alerts: Contact Method:
SSN Email
Birthday Sex Male Female
Marital Status Employer / School Name

Billing Information Is The Billing Address Different?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Insurance

Insurance Name:
Insurance Plan:
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 Insurance

Insurance Name:
Insurance Plan:
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

Reason for Visit:
Secondary Reasons:

Primary Care Physician: Last Visit: Reason:

Please list any medications you currently take:
Please list any drug allergies:

Vitamins Taken: Over the Counter Medications Taken:
Pregnant Or Nursing?:

Have you had any major injuries/surgeries/hospitalizations? If so, please describe:


Eye History

Do you have any of these eye conditions?
Do you use any of these eye medications?:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you have backup glasses? Do you want new glasses?

Type of contacts worn in past: What contact solution do you use?:
How long do you wear them?: How often are they replaced?:
Days per Week Worn: Hours Worn Comfortably:


Family Eye History

Does your family have a history of these eye conditions?

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Crossed/Lazy:


Review of Systems

General: Ear/Nose/Throat:
Skin: Musculoskeletal:
Endocrine: Cardiovascular:
Respiratory: Genitourinary:
Neurological: Gastrointestinal:
Psychiatric: Blood/Lymph:
Immune:


Social History

Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:

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