Please complete your health and clinical profile before your examination.
If you are already seated in our reception or office, please complete and submit this form now.
Demographic and direct contact information.
Responsible party details if different from patient info.
Separate medical insurance policies from routine vision care benefits.
Medical insurance covers ocular disease, emergencies, infections, injuries, cataracts, dry eye, diabetes, or medical ocular testing.
Important: VSP, EyeMed, and Delta Dental / Delta Vision are not medical insurance. Please record those under Routine Vision Coverage (Section 3) below.
The patient is not the primary policyholder for this plan.
Use this section for supplemental policies or secondary Medicare coverage.
Note: VSP, EyeMed, and Delta Dental / Delta Vision are routine vision plans typically utilized for wellness visits, frames, lenses, and contacts.
Delta Dental / Delta Vision: These benefits are processed via EyeMed. Please select "Yes" and choose EyeMed below.
The patient is not the primary policyholder for this vision plan.
Visual correction background and optical goals.
Note any known eye conditions for biological parents, grandparents, or siblings.
Include prescription drops, OTC lubricating drops, ointments, or eye vitamins.
Overall wellness, medications, conditions, and review of systems.
List prescription medications, dosage, and medical purpose if known.
Select any diagnoses that apply to your history:
Select any general medical conditions in your biological family. (Eye conditions are captured separately above).
Tap each biological system to select all symptoms or conditions that currently apply.
Since diabetes was selected above, please complete what you can below:
If you selected "Other" anywhere above, please clarify details here.
Please ensure your demographic and health records are accurate prior to submitting.
Securely transferring your clinical profile to our practice records. Please do not refresh.