Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information

Title	First	Last	MI	Suffix	Nickname	Pronoun

Address:

City:		State:		Zip Code:

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address the Same? Yes

Title	First	Last	MI	Suffix

Address:

City:		State:		Zip Code:
Home Phone:
Work Phone:

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:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Reason for Visit:
Secondary Reasons:

Do you have a history of any of the following?:
Do you take any eye medications?:

Last Eye Exam:

By Doctor:

Primary Vision Correction:

Back up specs?:

Planning to get new glasses?:

Contact Lens Wearers

Type of contacts worn in past:

Wear Time:

Cleaner:

Disposal:

Family Eye History

Macular Degeneration:		Glaucoma:
Retinal Detachment:		Cataracts:
Crossed/Lazy Eye:

Medical History

Do you have a history of any medical conditions?:

Please list any injuries, surgeries, or hospitalizations:

Pregnant Or Nursing?:

Recent Tetanus Shot? :

Primary Care Physician:

Last Visit:

Reason:

Do you take any medications?:

Are you allergic to any medications?:

Over The Counter Meds:

Birth Control:

Vitamins:

Does anyone in your family have a history of the following?:

Review of Systems

General:
Ear/Nose/Throat:
Cardiovascular:
Respiratory:
Genitourinary:
Musculoskeletal:
Skin:
Neurological:
Psychiatric:
Endocrine:
Blood/Lymph:
Allergy/Immune:
Gastrointestinal:

Social History

Hobbies:

Smoking Status:		Type:		How Long:
Alcohol Use:		Type:		How Long:
Illegal Drug Use:		Type:		How Long:

Preferred Language:

Race:

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