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:		MI:		Last:

Address:

City:
State:
Zip Code:
Cell Phone:
Home Phone:
Work Phone:
SSN
Preferred Contact Method:
Birthday
Email
Sex	Male Female
Occupation
Marital Status
Employment Status	Employed Full-Time Student Part-Time Student
Employer / School Name

Primary Medical

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:

Primary Vision

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

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Eye History

Reason for Visit:
Secondary Reason:

Do you take any of these eye medications?:

Have you had any eye surgeries? Please describe:

Last Eye Exam:

Medical History

No Meds Used

Medications:

No Known Drug Allergies

Drug Allergies:

Injuries/Surgeries:

Pregnant Or Nursing:
Primary Care Physician:		Last Visit:
Specialist:		Last Visit:

Do you have any of these medical conditions?:

Diabetes:		HBA1C Test:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:

Other:

Family Medical History

Unknown family history

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

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

Family Eye History

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

Macular Degen:		Glaucoma:
Retinal Detach:		Other:
Lazy/Crossed Eye:

Review of Systems

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

Social History

Hobbies:

Smoking Status:		Type:		How Long:
Race:		Ethnicity:		Preferred Language:

Submit Form

*Please Type your Name in BOTH signature boxes below AFTER reading BOTH policies*

No Show Appointment Agreement

Our office observes a 'no show' appointment policy. Failure to arrive within 10 minutes of your scheduled appointment will result in a 'no show appointment' and you may need to reschedule to another time. We understand that sometimes a scheduled appointment cannot be kept, however we kindly request that you notify our office at least 24 hours in advance to cancel or reschedule your visit. If you do not show for your appointment, we will consider this in violation of our agreement and you will be charged a fee of $35 for the missed appointment.

Signature:

Privacy Policy

I understand that I am entitled to a copy of this notice upon request. I have reviewed, or been made available a copy of the notice of Privacy Practices regarding HIPAA policies. I understand that my medical records are confidential and that by signing this form I am allowing my information to be released to my insurance company upon request. I hereby authorize payment of health insurance benefits. I also authorize access to my medical records to the person(s) listed.

Signature: