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: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address the Different?
Title First Last MI Suffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary

Insurance Information
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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
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:
Sex:
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!

Eye History

Vision Reason
No complaints - Wellness check
New glasses Rx
New Contact Lens Rx
Lasik Consult

Medical Reason
Diabetic Evaluation
Hypertension Evaluation
Glaucoma Evaluation
Cataract Evaluation
Dry Eye Evaluation
SLE Evaluation
Allergy Evaluation
Red Eye Evaluation
Other

Medical Symptoms
Blurred far vision Blurred near vision
Itching Burning
Tearing Discharge
Redness Irritation
Dryness Pain
Eyelid Problems Floaters
Flashes of light Glare/Halos
Double vision Light Sensitivity
Blind spots Headaches
Eye fatigue

Medical History

Referred By: Referring Doctor:

Family Patients:

Hobbies:

Interested In Contact Lenses? Ever Worn Contact Lenses?

Type of CLs worn in past: Back up specs for cls?

Primary Vision Correction:

Sunspecs? Computer glasses? Problems with glare?

Interested in Laser Vision Correction?

Medical Eye History

Eye Meds:

Last Eye Doctor: Primary Care Physician:

Systemic Meds:

Medical History

Immediate Family Med History: Family Eye History: Drug Allergies:

NOTES/SOCIAL HISTORY

Review of Systems

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

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