Patient information

Tell us a little about yourself. Fields marked with * are required.

Personal details

First name *

Middle initial

Last name *

Preferred name

Birthday

SSN

Birth sex *

Male Female

Pronoun

Contact information

Cell phone *

Home phone

Email *

Preferred contact method *

Mailing address

Street address *

Apt / Suite #

City *

State *

Zip code *

Employment & background

Occupation

Billing address

Billing address is different from my mailing address

Medical history

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Eye history

Please list any eye surgeries you've previously had

Medications & allergies

Medications

Over-the-counter medications

Vitamins

Drug allergies

General medical history

Please list any diagnosed medical conditions you have

Family medical history

Please list any diagnosed medical conditions in the family

Family eye history

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

Macular degeneration

Glaucoma

Retinal detachment

Blindness

Social history

Smoking status

Alcohol use

Pregnant or nursing

Ethnicity

Preferred language

Favorite flavor of chocolate

Milk Chocolate White Chocolate Dark Chocolate

HIPAA Policies

Required Checkbox*

We handle your personal data with the utmost safety and security. All of our staff have extensive HIPAA training and our software has state of the art HIPAA compliance measures. Our full HIPAA are available per request from the front desk. Please check this box to confirm that you've read this message.