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

*This field is required

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

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 Vision 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:

Primary 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

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

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Medical History

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Eye History

Reason for Visit

Primary Reason

Secondary Reason

Do you currently have any of these symptoms?

Do you currently take any of these medications?

Have you had any eye surgeries? Please describe

Last Appointment Type

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Medical History

Do you have any of these medical conditions?

Diabetes

Year Diabetes diagnosed if applicable

Hypertension

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Other

Medications No Medications

Over the Counter Medications

Drug allergies No Known Drug Allergies

Vitamins

Diabetes Type 1

Diabetes Type 2

Hypertension

Hypotension

Hypothyroidism

Hyperthyroidism

High Cholesterol

Depression

Anxiety

ADHD

Arthritis

Seizures

Migraines

Asthma

Allergies

Blood Thinners

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Recent Tetanus Shot

Recent Flu Immunization

Family Medical History

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

Unknown family history

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

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

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD