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

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Vision Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

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Medical History

Patient Medical History

Injuries, Surgeries, Hospitalization

PCP

Medical Insurance

Address

Last Visit

Reason For Visit

City, State, Zip

Recent Tetanus Shot

Pregnant or Nursing

Systemic Meds

Drug Allergies

OTC

LEE

Glaucoma Meds

Eye Meds

Vitamins

Doctor

Family Medical History

Diabetes

HTN

Hypercholesterolemia

Cancer

Kidney

Autoimmune Disease

Thyroid Disease

Heart Disease

SocialHistory

Occupation

Hobbies

STDs

STD Type

Tobacco

Type

How long

Frequency

Alcohol

Type

How long

Frequency

Illegal drugs

Type

How long

Frequency

Family Social History

Glaucoma

Cataracts

Macular Degen

Retinal Detach

Crossed/Lazy

Review Of Systems

General

Skin

Neurological

Endorcrine

Allergic/Immunologic

Respiratory

Ear, Nose, Throat

Cardiovascular

Gastrointestinal

Genital, Kidney, Bladder

Muscles, Bones, Joints

Blood/Lymph

Psychiatric

What is your #1 health concern?

Do you take any suppliments?

If no, Why?

Do you have interest in addressing your health concerns and investing in preventative care? Interest Level?

We are committed to improving your health. Vitamins and carotenoid antioxidants can help prevent and fight diseases. For a minimal fee of $10, would you like to have your antioxidants measured with our new technology to help you achieve better health?