Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

Home Phone

Preferred Contact Method

Birthday

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

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Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

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Medical History

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Medications currently taking:

Allergies to Medications:

Please Check all that apply

	Self	Family
Eye Injury
Floaters/Flashes
Lazy Eye
Cataract
Double Vision
Retinal Disease
Macular Degen
Eye Surgery
Headaches
Glaucoma

Other:

Surgeries and/or hospitalizations:

Pregnant?

Nursing?

Review of systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine/Diabetes

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular/High Blood Pressure

Dry Eye Questionnaire

1) Do you experience dryness in your eyes?
Yes No 2) Do you experience foreign body sensations within your eyes?
Yes No 3) Do you experience watery eyes?
Yes No

How did you hear about us?

All insurances must be presented at the time of service. Payment must be collected at time service is rendered. For insurance patients, please be aware that you are fully responsible for the services not covered by your insurance plan.