Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
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?
TitleFirstLastMISuffix
Address

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

Tertiary

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

Medical History

Eye History

Do you have a history of any of these eye conditions?

    Yes    No
Glaucoma     
Macular Degeneration     
Retinal Conditions     
Cataracts     
Blindness     
Crossed Eyes     
Lazy Eye     
Color Blindness     
Double Vision     
Serious Eye Infection     
Flashes/Floaters     

Other Eye Conditions? If so, please describe:
Have you had any eye surgeries? If so, please describe:
Have you had any eye injuries? If so, please describe:

Medical History

Do you have a history of any of these conditions?

    Yes    No
Diabetes        A1c:
High BP     
Thyroid Conditions     
Heart Conditions     
Cancer     
Arthritis     
Asthma     
Emphysema     
Migraines     

Other Medical Conditions? If so, please describe:

Do you take any medications? If so, please list:
Are you allergic to any medications? If so, please describe:

Primary Care Physician:

Family Eye History

Does your family have a history of any of these eye conditions? Family History Unknown

    Mom    Dad    Sibling    Paternal
  Grandma		    Paternal
   Grandpa		    Maternal
   Grandma		    Paternal
   Grandpa		    None
Glaucoma                                                   
Macular Degeneration                                                   
Retinal Conditions                                                   
Cataracts                                                   
Lazy/Cross Eye                                                   
Blindness                                                   

Other Family Eye Conditions? If so, please describe:

Family Medical History

Does your family have a history of any of these conditions?

    Mom    Dad    Sibling    Paternal
  Grandma		    Paternal
   Grandpa		    Maternal
   Grandma		    Paternal
   Grandpa		    None
Diabetes                                                   
High BP                                                   
Thyroid Conditions                                                   
Heart Conditions                                                   
Cancer                                                   

Other Family Medical Conditions? If so, please describe:

Social History
Race: Ethnicity: Preferred Language:

Smoking Status: Alcohol Use:

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