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

Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

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

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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Personal And Social History

Age

Occupation:

Referred By:

Referring Doctor:

Family Patients:

Hobbies:

Ever Worn Contact Lenses?

Are You Interested in Contact Lenses?

Type of CLs worn in past:

Back up specs for cls?

Primary Vision Correction:

Hours on computer

Problems with glare?

Medical, Personal And Family History

Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal

Eye Meds:

Last Eye Doctor:

Primary Care Physician:

Systemic Meds:

Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Pregnant,Nursing,HIV+

Family Med History:

Family Eye History:

Medication Allergies:

Review of systems

General: Fever, weight loss, weight gain, fatigue?

Ears, Nose, Throat:

Psychiatric:

Cardiovascular:

Endocrine:

Respiratory:

Blood/Lymph:

Genital, Kidney, Bladder:

Allergic/Immunologic:

Muscles, Bones, Joints:

Skin:

Neurological: