Insight Vision Center Optometry 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

Date of Birth

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Grade/Year in school (If applicable)

Pronoun

Gender Identity

Marital Status

Primary Guardian Full Name (If Applicable)

Secondary Guardian Full Name (If Applicable)

How did you hear about us?

Please share the name of the person or provider who referred you. (Optional, but helpful!)

Billing Information

Is the Patient Responsible for Paying for Their Care? No Yes

If no, you will be asked to provide the information for the responsible party below.

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Are you the primary policyholder for your vision insurance? Yes No

Do you have secondary insurance? Yes No

Secondary Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Are you the primary policyholder for your secondary insurance? No

Vision and Medical History

What Is the Main Reason for Your Visit?

Last Eye Exam

Doctor

Do you have any current eye conditions? (Examples: Retinal problems, cataracts, lazy eye, keratoconus, dry eyes)

What medications or supplements are you currently taking? (Include any prescription or over-the-counter eye drops)

Do you have any current medical conditions? (Examples: Diabetes, high blood pressure, cancer, heart disease, high cholesterol, thyroid issues)

Do you have any allergies to medications?

Have you had any injuries or surgeries to your body or eyes?

Do any medical or eye conditions run in your family? (Example: Mother has diabetes)

Are you currently pregnant or nursing?

Preferred Pharmacy

Social History

Hours of Screentime/ Hobbies/ Personal Information