Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Race: Preferred Language:

Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

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:

Secondary

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:

Tertiary

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:

Medical History



Reason for Visit:
Secondary Reasons:

Whom may we thank for referring you
Address or Phone Number
If you are a returning patient: Which reminder did you receive?

Today's Visit


Chief Visual Complaint: Which Eye?: Symptoms

Onset Meds Used CL Wearer

Secondary Complaint

Eye History


Last Eye Exam: Diagnosis: Doctor Prescribed:

Last eye doctors name Doctor's Address Doctor's Telephone:

Please check all eye conditions that apply to you
Have you ever had any Eye surgeries? Procedure Date:

Family Members With Eye Conditions (Blood Relatives Only):

My Has
My Has
My Has

Do You Wear?:

Computer eyeglasses Prescription Eyeglasses
Safety Glasses Prescription Sunglasses
Sports Googles
HOW OLD ARE YOUR CURRENT EYEGLASSES

Contact Lens History:


Do You Wear Contact Lenses If Yes, What Brand How Many Hours A Day Do You Wear Your Contacts
How Often Do You Dispose Your Contacts Do You Sleep Or Nap In Contacts What Solutions Do You Use To Clean And Disinfect Your Contacts?
Do You Wear UV Coated Sunglasses

General Health History


Last General Health Exam: Doctors name: Doctors Address: Doctors Phone:

Please Check All Health Conditions That Apply To You:

Seasonal Allergies Headaches
Arthritis Heart Disease
HIV Asthma
Hypertension Cancer
Lung Disease Diabetes
Vascular disease Seizures

Family Members With Health Conditions:


My Has
My Has
My Has

Heve you had any Medical Surgeries

Medications


I take For
I take For
I take For

Please list any additional Medications
Medication Allergies
Non Brand Medications

Lifestyle Questionaire


These Questions Are Intended To Assist Us In Better Meeting Your Everyday Visual Needs.

How many hours do you spend on a computer if any?
Reading / Deskwork? Outdoors Nightime Driving?

Which Sports Do You Participate In?

None
Baseball/Softball
Basketball
Fishing
Football
Martial Arts
Golf
Hunting
Tennis
Ice Skating
Snow Skiing
Soccer
Swimming
Water Skiing

I want the style of my frames to be
I want my frames to be made of
I want my lenses to be
Has There Been A Time When You Wish You Were NOT Wearing Eyeglasses
If yes, would you like to know if you are a candidate for contact lenses
Are you interested in colored contacts

Social History


Alcohol Tobacco Drugs

Race: Preferred Language:

Review of Systems

General: (ex. Fever, Weight loss, Weight gain, Fatigue)
Ear/Nose/Throat: (ex. Allergies, Sinus, Cough, Dry Mouth / Throat)
Cardiovascular: (ex. High BP, Heart Surgery, Vascular Disease)
Respiratory: (ex. Asthma, Bronchitis, Emphysema, COPD)
Genitourinary: (ex. Kidney Stones, Frequent Urination, Impotence)
Musculoskeletal: (ex. Athritis, Joint Pains, Head or Neck Injury)
Skin: (ex. Growths, Rashes, Acne)
Neurological: (ex. Headaches, Migraines, Seizures)
Psychiatric: (ex. Depression, Anxiety, Insomnia)
Endocrine: (ex. Thyroid, Diabetes)
Blood/Lymph: (ex. Anemia, Cholesterol, Bleeding Problems)
Allergy/Immune: (ex. Seasonal Allergies, AIDS, Lupus)
Gastrointestinal: (ex. Diarrhea, Constipation, Ulcer, Reflux)


Patient Signatures / Submit Data


HIPAA Privacy Policy, Financial Agreement: Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

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Patient Signature Date:

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Patient Signature Date:

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Patient Signature Date:

***By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I accept has the same validity and meaning as my handwritten signature.