Online Patient Forms

Patient information

First name

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Last name

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Nickname

Address

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City

State

Zip Code

Home Phone

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Cell Phone

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Work Phone

Other Phone

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Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Gender

Male Female

Marital Status

Misc/Guardian

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Medical History

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Eye History

Primary reason for visit

Secondary reason for visit

Do you currently have any of these eye symptoms?

Do you currently take any of these medications?

Last Eye Exam

By Doctor

Primary Vision Correction

How long?

Medical History:

Please list patient medical history(Arthritis, Asthma, Diabetes, High blood pressue, Heart disease, etc.)

Please Describe any Injuries or Surgeries you have had

Medications No Medications

Over the Counter medications

Vitamins

Drug allergies

Glaucoma medications

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Family Medical History

Unknown Family History

Please list family medical conditions.(Arthritis, Cancer, Diabetes, High blood pressue, Heart Disease, Kidney, Thyroid, etc.)

Family medical history 2

Family medical history 3

Family medical history 4

Family medical history 5

Family medical history 6

Family Eye History

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

Macular Degen

Glaucoma

Retinal Detach

Blindness

Cataracts

Lazy/Crossed Eye

Other

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Do you drive?

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

Signatures

Master Eye Associates
WE ARE COMMITED TO EARLY DETECTION AND PREVENTION OF EYE DISEASE. WE STRONGLY RECOMMEND THAT ALL OF OUR PATIENTS RECEIVE BOTH TESTS AS PART OF THEIR COMPREHENSIVE VISUAL ANALYSIS.

A DILATED FUNDUS EXAM enables us to provide a more thorough ocular health analysis. with the dilated pupils, we get a better view inside the eye that allows us to detect early signs and changes of ocular pathologies. A Dilated Fundus Examis extremely essential for diabetics, hypertensives, high myopes, and/or any history of other related ocular diseases. the side effects are lurred near vision and light sensitivity. in some individuals, the distance may also be blurred.

A VISUAL FIELD ANALYSIS is a highly computerized instrument that provides us a more thorough analysis of your field of vision. Visual Field Screening can assist us in early detection of glaucoma, retinal problems, and some neurological diseases, and may diagnose cause of headaches.

There is an additional $20.00 fee for the dilated fundus exam and $20.0 for the visual field screening. Please check the appropriate space below stating your preference.

Dilated Fundus Exam Yes No

Visual Field Screening Yes No

E-Signature

Date

*I understand that without these tests certain eye disease and conditions may not be discovered. I agree to assume all risk associated with refusing these tests, indemnify, old harmlesss, and release Master EYe associates, its employees and optometrist, from anyoneand all claims or liability whatsoever related to failure to diagnose and or treat any eye condition due to lack of diagnostic information whic could have been obtained by these tests.

Please click Here to view our Notice of Privacy Practices

I hereby acknowledge that I have been provided with a copy of the Privacy Policy. I hereby refuse to acknowledge recipt of the Policy. I understand that even though I may refuse to sign this acknowledgment, Provider may still provide treatment to me.

E-Signature

Date

Patient information

Billing information

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Medical History

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Eye History

Medical History:

Family Medical History

Please list family medical conditions.(Arthritis, Cancer, Diabetes, High blood pressue, Heart Disease, Kidney, Thyroid, etc.)

Family Eye History

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

Review Of Systems

Social History

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