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	Pronoun

Address:

City:	State:	Zip Code:

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
SSN		Email
Birthday		Occupation
Birth Sex	Male Female	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?

Title	First	Last	MI	Suffix

Address:

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

Primary Medical Insurance

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:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Medical Insurance

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:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Primary Vision Insurance

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:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Vision Insurance

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:	Spouse Child Other
Sex:	Male Female
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!

Parent's Name:
School:
Grade:
Hobbies/Sports:
Child's Pediatrician:

Has Your Child Received Any Special Guidance/Assistance/Testing (OT/PT, AIS, IEP, 504, RTI) etc...

What is your main reason for visit?:

Do you wear glasses?:	Yes	No
If yes, do you wear them for:	Distance	Near	Both
Do you wear Contacts?:	Yes	No

Date of Last Eye Exam:
Date of Last Medical Exam:
Primary Care Physician:

Do you have any allergies to medication?:

Yes

If yes, please list:

Do you have seasonal allergies?:	Yes	No
Are you taking medications?:	Yes	No

List Medications:

List Eye Medications:

Pharmacy:

Do you have:

None

High Blood Pressure

Diabetes

High Cholesterol

Thyroid Disease

Rheumatoid Arthritis

Asthma

Lyme Disease

Multiple Sclerosis

Cancer

Have you ever had eye surgery for:

None

Cataract

Lasik/PRK

Muscle Surgery

Retinal Detachment

Trauma

Foreign Body Removal

Other

Have you ever had:

None

Strabismus (eye turn)

Amblyopia (lazy eye)

Keratoconus

Glaucoma

Diabetic Retinopathy

Macular Degeneration

Dry Eyes

Iritis

Retinal Detachment

Does anyone in your family have: Unknown family history

None
Retinal Detachment
Glaucoma
Cataracts
Macular Degneration
Keratoconus
Diabetes
High Cholesterol
High Blood Pressure
Thyroid Disease

Are you pregnant?:	Yes	No
Do you see flashes of light in your eyes?:	Yes	No
Do you see floating objects in your eyes?:	Yes	No
Do you have frequent headaches?:	Yes	No
Do you smoke?:	Yes	No
Do you drink alcohol?:	Yes	No

Hobbies:

Number of hours spent on computer:

Do you currently have any of these problems?

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

Submit Form / Patient Signature

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I understand that I am financially responsible for any charges for services rendered and/or any balance remaining after payment of possible insurance benefits.