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

Birthday: SSN: *SSN is required for insurance purposes. If you are uncomfortable providing this information online, please contact our office @ 406 522 8888
Address: Apt/Suite #:
City: State: Zip Code:
Cell Phone: Home Phone:
Work Phone: Email
Preferred Contact?: Sex:
Employer / School Occupation
Marital Status Race:
Spouse Name: Contact Info:

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:
City: State: Zip:
Phone Number:


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?:

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: Over The Counter Medications:
Vitamins: 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:

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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