Online Patient Forms

Patient Information

Upload Driver Lisc [front]:

Front of the card preview

Upload Driver Lisc [back]:

Back of the card preview

First Name

*This field is required

Last Name

*This field is required

Nickname

Birth Sex

Male Female

*This field is required

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

Authorized persons to release medical information to:

Billing Information

Is The Billing Address Different?

Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

Apt/Suite:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Relationship Options:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Secondary Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

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:

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

Patient Eye History

CHIEF COMPLAINT

Secondary Complaints

REVIEW OF OCULAR SYSTEM: Injuries, Infections, Surgeries, Diseases

Eye Meds

Last Eye Exam

Doctor

Primary Vision Correction

Do you want New Glasses?

Do you have Backup Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Wear Time

Cleaner

Disposal

Patient Medical History

HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid

Over the Counter Medications

Vitamins

Injuries, Surgeries, Hospitalization

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Recent Tetanus Shot

Family Medical History

Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

Family Eye History

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

Macular Degeneration

Glaucoma

Retinal Detachment

Cataracts

Lazy/Crossed Eye

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD