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Demographics

General Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
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
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Insurance

Insurance Information
Insurance Name:
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

Personal and Social History Referred By: Referring Doctor: Family Patients:
Please list all your Hobbies:
Ever Worn Contact Lenses? Type of CLs worn in past: Interested In Contact Lenses?
Primary Vision Correction: Do you have Sunspecs? Do you have Computer Specs?
Interested in Laser Vision Correction?
Medical, Personal and Family History Primary Care Physician: Last Eye Doctor:

Please select your current Eye Medications (if not listed please type in box below):
None Acular Artificial Tears Betoptic-S 0.25% Betoptic 0.5% Betagan Erythromycin FML FML Forte Gentamicin
Neosporin Ocupress Pilo Gel Propine Polytrim Pred Mild Pred Forte Patanol Timoptic 0.25% Timoptic 0.5%
Tobradex Voltaren Xalatan


Please select your current Eye History (if not listed please type in box below):
None Abrasion Blind Eye Blepheroplasty Cataract - Both Eyes Catatract - Right Eye Catatract - Left Eye
Conjunctivitis Glaucoma IOL-Both Eyes IOL -Right Eye IOL -Left Eye Metal in Eye Ptosis
Retinal Detachment Weak Eye Lazy Eye


Please list any Prescription Medications:


Please select your current Medical History (if not listed please type in box below):
None HAs Arthritis Asthma Diabetes
HIV+ Nursing Seizures Thyroid High Blood Pressure Smoke Pregnant Inflamed Bowel Disorder


Please select your Family Medical History (if not listed please type in box below):
None Cancer Diabetes I Diabetes II Hypertension
Thyroid Heart Disease Seizures Hypercholesterolmia High Blood Pressure


Please select your Family Eye History (if not listed please type in box below):
None Abrasion Blind Eye Blepheroplasty Cataract - Both Eyes Catatract - Right Eye Catatract - Left Eye
Conjunctivitis Glaucoma IOL-Both Eyes IOL -Right Eye IOL -Left Eye Metal in Eye Ptosis
Retinal Detachment Weak Eye Lazy Eye


Please list Medication and Seasonal Allergies:

NOTES/SOCIAL HISTORY

Submit Data


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