Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:

City:	State:	Zip Code:

Home Phone:		Work Phone:
Other Phone:
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

Billing Information

Is The Billing Address the Same? Yes

Title	First	Last	MI	Suffix

Address:

City:	State:	Zip Code:
Home Phone:
Work Phone:

Primary 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:

Secondary 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

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

Referred By:

Referring Doctor:

Family Patients:

Hobbies:

Interested In Contact Lenses?

Ever Worn Contact Lenses?

Type of Contact Lenses worn in past:

Do you have backup glasses?:

Primary Vision Correction:

Do you wear sunglasses?:

Do you wear computer glasses?:

Do you have problems with glare?:

Interested in Laser Vision Correction?

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

Eye Meds:

Last Eye Doctor:

Primary Care Physician:

Please list all medications:

Medication and Seasonal Allergies:

Please describe any medical condition you have or have previously had: