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

	First	Last	MI

Birthday:		SSN	Sex: Male Female
Address:		Apt/Suite #:
City:		State:	Zip Code:
Cell Phone:		Home Phone:
Work Phone:		Email
Preferred Contact?:
Employer / School		Occupation
Marital Status		Race:
Spouse Name:		Contact Information:

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:

Referral

Who may we thank for referring you to our office? Name of friend or relative:

How did you choose our office if not from a friend or relative?:

Doctor Referral:		Insurance List
Web Page:		Saw Sign/Building
Other:

Medical History

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

Please tell us why you're here today:

Previous Eye Doctor:

Date of Last Exam:

Primary Vision Correction:

Do you: Have back up glasses?

Want new glasses?

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

Days per week worn:

Hours per day worn:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:

Family Eye History

Macular Degen:		Glaucoma:
Retinal Detach:		Cataracts:
Lazy/Crossed Eye:

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Please describe any injuries or surgeries you have had:

Primary Care Physician:

Last Visit:

Reason:

Pregnant Or Nursing:

Recent Tetanus Shot:

Family Medical History

Please select any conditions that apply to your family:

Review of Systems

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

Social History

Hobbies:

STD's:

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

Ethnicity:

Preferred Language:

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