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

If the patient is a minor or is not responsible for the charges for the visit,
please complete this section with the responsible party's information.

Is The Billing Address the Same? Yes

Title	First	Last	MI	Suffix

Address:

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

Medical History

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

Reason for Visit:	Secondary Reasons:

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Please describe any injuries or surgeries you have had:

Primary Care Physician:

Last Visit:

Reason:

Pregnant Or Nursing:

Recent Tetanus Shot:

Recent Flu Immunization:

Do you have any of these medical conditions? If yes, please describe:

Diabetes:		Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions? If yes, please describe:

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:

Have you had any eye surgeries? Please describe:

Last Eye Exam:

By Doctor:

Primary Vision Correction:

Do you: Have back up glasses?

Want new glasses?

Want backup sunglasses?:

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

Family Eye History

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

Review of Systems

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

Social History

Hobbies:

STD's:

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

Race:

Ethnicity:

Preferred Language:

Submit Form

**Click here to view our Notice of Privacy Practices**

Receipt of Notice of Privacy Practices

I, acknowledge that I have received the Notice of Privacy Practices of Jeffery E. Gates, OD and Associates.

Signature:
Date Signed:

Signature of Personal Representative of Patient:
Relationship of Person to Patient:

**Click here to view our Patient Financial Responsibility Policy**

Patient Financial Responsibility Policy

Your signature indicates that you have read, understand, and agree to all the above policies.
As a responsible party, your signature indicates acceptance of the above policies and authorizations.

Signature:		Relationship to Patient:
Date:		Patient Date of Birth: