Online Patient Form

Click here to print a blank copy of this form.

After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information


TitleFirst*Last*MISuffixNickname
Address:
City: State: Zip Code:
Home Phone:* Work Phone:
Other Phone: Alerts:
Cell Phone:* Preferred Contact:
SSN Email     
Birthday* Occupation
Sex Employment Status
Marital Status Employer/School:
Misc/Guardian

How did you hear about our office?:

Billing Information

Is The Billing Address the Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
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!

Reason for Visit: Secondary Reasons:

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:

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: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:

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


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:
Other:

Review of Systems

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

Family Medical History



Does anyone in your family have any of these medical conditions? If yes, please describe:

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Eye History

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

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:

Submit Form

Electronic Signature Agreement:

By signing below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By signing using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Atasca Eye Center.

You are also confirming that you are the authorized to enter into this Agreement. You further agree that by your E-Signature, you agree to be bound by the terms and conditions of Disclosures and Agreement as they exist on the date of your E-Signature on this form. You may withdraw your consent at any time after you have stated such withdrawal in writing and we have had a reasonable opportunity to act upon it.

HIPPA Patient Privacy Notice:

**Click here to view our Privacy Notice**

I certify that I have been provided Atasca Eye Center's Patient Information Privacy Notice.

Signature: Date:

You will need:

  1. Photo ID such as driver's license
  2. Current insurance cards (both medical & vision) if applicable
  3. Spectacles wearers: most recent glasses and/or glasses Rx
  4. Contact Lens wearers: most recent CL boxes for each eye and/or CL Rx
  5. List of medications or medication bottles including eye drops
  6. Any relevant medical records pertaining to eye history
  7. Doctor referral form if applicable

Note: In order to be respectful to the eye care needs of other patients, please give us a 24 hour advance notice if you are unable to show up for an appointment. A "No Show" or late cancellation without a prior 24 hours notice will be assessed a fee of $30.