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

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:

Eye History

Please choose from the menu options

Chief Complaint

Secondary Complaint

Ocular History (Injuries, Infections, Surgeries, Diseases, etc)

Ocular Meds:

Last Eye Exam:

By Doctor:

Family Ocular History

Macular Degeneration

Glaucoma

Cataracts

Retinal Detachment

Lazy/Crossed Eye

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Primary Care Physician

Last Visit

Office Phone:

Systemic Meds:
(Please list any medications currently taking)

Drug Allergies

Over the counter medications

Birth control

Patient Medical History

Please list any medical history:
(Arthritis, Asthma, Diabetes, High blood pressure, Heart Disease, Seizures, Thyroid, etc)

Injuries, Surgeries, Hospitalizations

Pregnant or Nursing

Diabetic

Family Medical History

Please list any family medical history:
(Arthritis, Asthma, Diabetes, High blood pressure, Heart Disease, Seizures, Thyroid, etc)

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

Review of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular