Patient Information

Billing Information

Primary Vision Insurance

Primary Medical Insurance

Medical History

Online Child Patient Forms

First Name

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Last Name

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Nickname

Birth Sex

Male Female

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Address

Apt/Suite #

City

State

Zip Code

Cell Phone

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Home Phone

Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

Is The Billing Address Different?

Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

Apt/Suite:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Insurance Information

Insurance Name:

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Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Relationship Options:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Insurance Information

Insurance Name:

*This field is required

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:

Macular Degeneration

Retinal Conditions

Lazy/Cross Eye

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Eye History

Reason for Visit

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Secondary Reason

Do you currently have any of these symptoms?

Do you currently take any of these eye medications?

Have you had any eye surgeries? Please describe

Last Eye Exam

Do you or any family members have any of these eye conditions?

Medical History

Medications

No Medications

Vitamins/Supplements

Drug allergies

No Known Drug Allergies

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Pregnant or Nursing

Last Physical Exam

Do you or any family members have any of these medical conditions?

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Alcohol Use

Race

Ethnicity

Preferred Language

Child History

School Information

Name of Child's School

Child's Teacher

Child Started Kindergarten

Child Entered 1st Grade

Repeated grade

What Grade?

Parent Information

Father's Legal Name

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Father's Address

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Father's Date of Birth

*This field is required

Father's SSN

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Father's Work Phone #

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Father's Email

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Father's Marital Status

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Father's Occupation

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Father's Employer

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Mother's Legal Name

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Mother's Address

*This field is required

Mother's Date of Birth

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Mother's SSN

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Mother's Work Phone #

*This field is required

Mother's Email

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Mother's Marital Status

*This field is required

Mother's Occupation

*This field is required

Mother's Employer

*This field is required

Emergency Contact

*This field is required

Contact for Appointment/Care

*This field is required

Contact for Billing/Insurance

*This field is required

Pregnancy / Birth History

Delivery Type

Problems during Pregnancy?

Problems during delivery?

If Yes, please explain

When was your child born

How Early

How Late

Birth Weight

Apgar Score

Developmental History

Meeting Developmental Milestones?

If No, please explain

Started crawling by what age?

Started Walking by what age?

Is your child reading?

Reading Level?

Left Handed

Right Handed

Therapies Receiving/Received

Behavioral Resource

Occupational

Vision

Physical

Speech

Tutoring

Visual Symptoms

Amblyopia (Lazy Eye)

Type of Treatment

Age when eye turn was noticed?

How did eye turn start?

Which eye turns?

When does eye turn?

Which direction?

Time of day?

Type of Treatment (Strabismus)