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


TitleFirstLastMISuffixNickname
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 Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Vision Insurance

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 Insurance

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!

Reason for Visit: Secondary Reasons:

Are you currently experiencing any of these symptoms?:

Estimated reading ability?:

Do you feel you are performing up to your potential at work or school?:

Do you ever work at a computer?
If so, how long?:

How long can you read before you notice visual fatigue?
How many hours daily do you spend reading or working at near distances?
How do your eyes feel after the computer work, reading, or studying?
Is there any other information you feel would be helpful / important in your treatment?

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:

Last Eye Exam: Type of Exam: By Doctor:

Primary Vision Correction:

Do you have glasses?: How many hours a day do you wear glasses?:
Do you want new glasses? Do you want backup sunglasses?:

Do you have visual difficulty when driving?:
Do you have problems with night vision?:


Contact Lens Wearers only
Type of contacts worn in the past: Cleaner:
Disposal: Wear Time:

Do you use lens rewetting drops?:

Do you take antihistamines, blood pressure medications, oral contraceptives, antidepressants, and/or cholesterol-lowering medications?:
If yes, please specify:

How many weeks in a year do you travel?: weeks

Do you experience:

Rate how your lenses feel immediately AFTER you first put them IN:
Rate how your lenses feel immediately BEFORE you take them OUT:

Family Eye History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Color Blindness:

Personal Medical History

Do you have any of these medical conditions? If yes, please describe:

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Lupus:
Arthritis:
Stroke:
Other:

Family Medical History



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

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Lupus:
Arthritis:
Stroke:
Other:

Medications, Allergies, Other History

Medications: Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:

Pregnant Or Nursing: Recent Tetanus Shot: Recent Flu Immunization:


Review of Systems

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

Social History

Hobbies: STD's:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long:

Race: Ethnicity: Preferred Language:

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