Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday(MM/DD/YYYY)

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Medical Insurance

(Medical insurance card must be presented to the front desk at the time of examination or the appointment may be rescheduled.)

Insurance Information

Insurance Name:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Vision Insurance

(Note: Patients with Superior health plan must present their insurance card at the time of examination or the appointment will be rescheduled.)

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

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Medical History

Please choose from the menu options

Chief Complaint

Referred by:

Do you want Contact Lenses?

Have you worn Contact Lenses?

Wear time

Type of Contact Lens used

Dx/MF/MONO?

Ocular History

Past Medical History

*This field is required

FAMILY Eye History

*This field is required

FAMILY Health History

*This field is required

Where was your last examination?

When?

Who is your family Doctor?

Last medical examination?

Medications

Allergies

Review Of Systems

*ALL fields are required in this section.

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Pre-Diabetes YES NO

Diabetes YES NO

What YEAR were you diagnosed with Diabetes?

Last Blood Fasting Glucose Level was:

Last taken?

When was the last time you had your cholesterol checked?

Pregnant or Nursing:

Smoking Status