Online Patient Forms

Patient Information

Upload Driver Lisc [front]:

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Upload Driver Lisc [back]:

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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

SSN

Occupation

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

Please choose from the menu options or select the option to type in your own text. Thank you!

Eye History

Primary Reason for Visit

Secondary Reason for Visit

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?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Eye History Questionnaire:

1. How frequently do your eyes feel dry, gritty, or scratchy?

2. How frequently do your eyes feel sore or irritated?

3. How frequently do you feel your eyes burning or watering?

4. How frequently do your eyes feel fatigued?

5. Is your vision worse at the end of the day?

6. Do you feel stiffness/pain in your neck/shoulders when you work at a computer or read?

7. Do you feel discomfort with computer use in your eyes (redness, burning) after long hours looking at the screen?

8. Do you feel light sensitivity especially with brighter, stronger lights like fluorescents or headlights?

9. Do you feel motion sickness/dizziness/vertigo?

10. Do you grind your teeth or feel tight in your jaw?

Family Eye History

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

Macular Degeneration

Glaucoma

Retinal Detachment

Cataracts

Lazy/Crossed Eye

Medical History

Medications

No Medications

Over the Counter Medications

Vitamins

Drug allergies

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Recent Tetanus Shot

Do you or anyone in your family have any of these medical conditions?

Diabetes

Year Dx

HbA1C

High Blood Pressure

High Cholesterol

Thyroid

Heart Conditions

Cancer

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Patient Signatures

Please review the following documents. Sign below to acknowledge and attach your signature to the final PDFs.

Optomap and Dilation -View the Optomap Form-

I elect to have the Optomap procedure at an additional fee of only $39.

I elect to have dilation- please do not drive until your vision clears up in 2-3 hours

I would like to discuss further with the technician before making a decision.

I am declining the Doctors' recommendation to obtain a comprehensive view of my retinas.

Please ADD the above numbers together.

Patient Information

Billing Information

Primary Insurance

Eye History

Eye History Questionnaire:

Do you or anyone in your family have any of these medical conditions?