Online 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

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Medical Insurance

Medical insurance name and ID are required fields. If you do not have insurance, please select 'None' for both.

Insurance Information

Insurance Name:

*This field is required

Insurance Plan:

Insurance ID:

*This field is required

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:

Vision Plan

Insurance Information

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

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Other Insurance

Insurance Information

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

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!

Chief Complaint

Reason for Visit

Location:

Severity:

Quality:

Duration:

Timing:

Context:

Modifying:

Associated:

Secondary Complaints:

Eye History

Do you experience any of the following

Double vision

Dryness

Discharge

Redness

Itching

Burning

FBS

Tear

Glare

Photosensitive

Eye Pain

Eye infection:

Floaters

Flashes

Eyestrain

Cataracts

Eye Turn

Glaucoma

Macular Deg.

Retinal detach

Other retinopathy

Amblyopia

Eye injury

Eye surgery:

Last Eye Exam:

Doctor:

Glasses:

Contacts:

Family Eye History

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

Unknown family eye history

Macular Degeneration

Glaucoma

Retinal Detachment

Cataracts

Eye Turn

Social History

Hobbies

Tobacco:

Type:

How long:

How much:

Alcohol:

Type:

How long:

How much:

Illegal Drugs:

Type:

How Long:

Medical History

Primary Care Physcian:

Last Visit:

Pregnant Or Nursing:

Drug Allergies:

Eye drops

Systemic Meds:

Other Meds Not listed:

Family Medical History

Does anyone in your family have any health conditions?

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

For Contact Lens Patients Only

Brand Of Contact Lens	Power	Base Curve	Diameter
OD
OS

Solutions Used:

Avg Wear Time:

Age of Contacts:

Disposal Sched:

Sleeps in lenses

How many continuous nights?