Online Patient Form

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After completing all the forms, please submit your data on the final tab. Thank you!

All fields marked with a * are required.
Please fill out the forms if you are a new patient, or any info has changed.

All patients please fill out the COVID-19 Screening.

COVID-19 SCREENING

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition Yes No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact
With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared
For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact
With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis,
Or Have You Been Asked To Quarantine?

Demographics


Patient Information
TitleFirst*Last*MISuffixNickname
Address:
City: State/ZipCode
Home Phone:* Work Phone:
Other Phone: Alerts:
Cell Phone:* Preferred Contact Method:
SSN* Email
Birthday* Occupation
Sex* Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer / School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
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!

Medical History
Reason for Visit:*
Secondary Reasons:

Last Exam: Primary Care Physician:
Last Eye Exam Eye Doctor:

Major Injuries/Surgeries:*
Eye Injuries/Surgeries:*
Other Medical History:
Other Eye History:

Eye Drops: Medications: No Meds
Vitamins: Allergies: None

Check the box for any conditions that apply: Family Hx Unknown, Patient is Adopted

You Mother Father Sibling No Describe (type, when diagnosed, etc)
Diabetes*               
Hypertension*               
Thyroid*               
Cardiovascular*               
Cancer*               
 
Glaucoma*               
Mac Degen*               
Retinal*               
Cataract*               
Lazy/Crossed Eye*               
Review of Systems
General:* Ear/Nose/Throat:*
Respiratory:* Cardiovascular:*
Endocrine:* Genitourinary:*
Skin:* Gastrointestinal:*
Neurological:* Musculoskeletal:*
Immune:* Psychological:*
Blood/Lymph:*
Social History
Smoking Status Alcohol
Illegal Drugs
Pregnant/Nursing:

Race:
Ethnicity: Preferred Language

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Submit Data