Online Patient Form

Click here to return to the previous website.

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

Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:

City:		Zip Code:

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
Misc/Guardian

Billing Information

Is The Billing Address The Same? Yes

Title	First	Last	MI	Suffix

Address:

City:		State:		Zip Code:
Home Phone:
Work Phone:

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:

Secondary 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:

Primary Reasons:	Secondary Reasons:

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:

Last Appointment Type

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:

Medical History

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known 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:

Do you have any of these medical conditions?:

Diabetes:		Year Diagnosed:
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:		Cataracts:
Lazy/Crossed Eye:		Blindness:

Social History

Hobbies:

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

STD

Submit Form