Patient Forms

Demographics

Patient Information

First

MI

Last

Suffix

Nickname

Address

City

State/Zipcode

Cell Phone:

Home Phone:

Work Phone:

Other Phone:

Email:

Preferred Contact Method:

SSN

Birthday

Sex

Male Female

Marital Status

Misc/Guardian

Employment Status

Employed Full-Time Student Part-Time Student

Occupation

Employer / School Name

Is the Billing Address Different?

Vision Insurance

Insurance Information:

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary on Account

Primary on Account

Name (Last, First, MI):

Relationship to Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip:

Phone Number:

Birthday:

SSN:

Employer/School:

Medical Insurance

Insurance Information:

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary on Account

Primary on Account

Name (Last, First, MI):

Relationship to Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip:

Phone Number:

Birthday:

SSN:

Employer/School:

Chief Complaints

Patient Ocular Conditions

Reason(s) for visit:

Eye History

Do you currently have any of these eye symptoms? Select all that apply:

Last Eye Exam:

Last Eye Doctor:

Glasses

Please select all types of glasses currently worn:

Contact Lenses

Do you wear contact lenses?

How often do you replace your current contact lenses?

Family Ocular History

Does anyone in your family have any of these eye conditions?

Unknown family history

Glaucoma:

Cataracts (cloudy eye lens):

Macular Degeneration:

Retinal Detachment:

Crossed / Lazy Eye:

Blindness:

Other family ocular issues:

Demographics

Race:

Ethnicity:

Preferred Language:

Medical History

Review of Systems

Ear, nose, throat:

Cardiovascular:

Respiratory:

Genial, kidney, bladder:

Muscles, bones, joints:

Skin:

Neurological:

Pyschiatric:

Blood/lymph:

Allergic / Immunologic:

Gastrointestinal:

General:

Endorcrine:

Diabetes (date of diagnosis):

Hemaglobin A,C (HbA1C):

Taken:

Medical History, Meds, Allergies

Primary care physcian:

Last primary care visit:

Medications

Vitamins / Over the counter medications:

Please describe any injuries or surgeries you have had. Also list any medication allergies:

No current medications No known drug allergies

Family Medical History

Does anyone in your family have any of these medical conditions?

Unknown family history

Diabetes (might want to check this):

Hypertension:

Heart Disease:

Cancer:

Thyroid Disease:

Arthritis:

Other:

Social History

Pregnant or Nursing:

STD's:

Alcohol Use:

Smoking Status:

Illegal Drug Use:

Online Patient Form

Demographics

Patient Information

Billing Information

Vision Insurance

Insurance Information:

Primary on Account

Medical Insurance

Insurance Information:

Primary on Account

Chief Complaints

Patient Ocular Conditions

Eye History

Glasses

Contact Lenses

Family Ocular History

Demographics

Medical History

Review of Systems

Medical History, Meds, Allergies

Family Medical History

Social History

Submit Data