Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer/School Name
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical Insurance

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Insurance

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Referred By:
Referring Doctor:
Family Patients:
Hobbies:
Interested In Contact Lenses?
Ever Worn Contact Lenses?
Type of CLs worn in past:
Back up specs for cls?
Primary Vision Correction:
Interested in Laser Vision Correction?
Last Eye Doctor:
Primary Care Physician:
Eye Hx: Infections, Injuries, Surgeries
Family Eye History: (GLC, AMD)
Eye Meds:
Systemic Meds:
Med Hx: (Diabetes,HTN,Seizures,Thyroid,Arthritis)
Family Med History:
Drug or Seasonal Allergies:

SYSTEM
DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

General:
Ears, Nose, Throat:
Cardiovascular:
Respiratory:
Genital, Kidney, Bladder:
Muscles, Bones, Joints:
Skin:
Neurological:
Psychiatric:
Endocrine:
Blood/Lymph:
Allergic/Immunologic

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