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

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Marital Status

Misc/Guardian

Primary Doctor

Preferred Pharmacy

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:

Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

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:

Vision Insurance

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:

Medical History

Please answer none if question does not apply.

Referred By

Primay Care Physician and exam date

OTC Medications

Seasonal allergies

Have you experienced any of the following:
Headache, Arthritis, Asthma, Diabetes, High Blood Pressure, Heart Disease, Inflammatory Bowel Disease, Seizures, Thyroid, Pregnant, Nursing, HIV+

Current medications, including vitamins:

Do you smoke?

Do you drink alcohol?

Do you use recreational drugs?

Preferred Language

Family History

Describe family history and which family member has the following history: Ex...(Diabetes-Father)

Family Medical History

Family Eye History

Family Patients

Patient Ocular Information

Eye History

Have you experienced: Sting, Burn, Itch, Surgery,Injury,Cataracts,Lazy Eye, Floaters, Glaucoma, Retinal Problems

Current Eye Medicaition

Last Eye Doctor and exam date

Primary Vision Correction

Are you interested in contact lenses?

Have you ever worn contacts lenses?

What type of contact lenses have you worn in the past?

Do you have a backup pair of glasses for your contact lenses?

Do you currently wear sunglasses?

Are you interested in Laser Vision Correction?

Any additional info