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!

* = Required fields

Patient Information

Title * First * Last MI Suffix Nickname
Address: Pronoun:
City: State: Zip Code:
Home Phone: * Cell Phone:
* SSN (Last 4) Email
* Birthday
Birth Sex
Employer / School Name

Billing Information

Is The Billing Address the Same?
Title First Last MI Suffix
City: State: Zip Code:
Home Phone:
Work Phone:

Medical History

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


* Reason For Today's Visit:
Eye History (Injuries, Surgeries, etc):
I Currently Wear Glasses: Full-Time Part-Time Type of Glasses?
I Currently Wear Contacts: Full-Time Part-Time
Are your lenses comfortable? Yes No
Please list all eyedrops you use (OTC and Rx): How often used?

Do You Have History Of The Following?

Yes No Yes No
Blindness Glaucoma
Eye Turn (Strabismus) Cataracts
Lasy Eye (Amblyopia) Macular Degeneration
Keratoconus Retinal Detachment

Are You Currently Experiencing Any Of The Following?

Yes No Yes No
Headaches Itchy eyes
Blurred Vision Burning eyes
Flashing Lights Double Vision
Exessive tearing Floaters

Other eye disease or condition: How many hours a day do you use a computer?


Physician's Name: Last Visit Date:

List All Medications You Are Currently Taking (Including Any OTC/Vitamins): List Any Medications You Are Allergic To:

Are You Pregnant Or Nursing? Yes No If Yes, What Is The Due/Birth Date?

Do you have, any following medical conditions?

Yes No Yes No Yes No
Migraines Arthritis High Blood Pressure
Multiple Sclerosis Allergies/Hay Fever Stroke
Diabetes Asthma Anemia
Thyroid Problems Emphysema Cancer
High Cholesterol Digestive/GI Rheumatoid Arthritis

Any History Of The Following In Any Family Members (Parents, Grandparents, Siblings)?        Family History Uknown
Yes No Relationship To Patient Yes No Relationship To Patient
Poor Vision Cancer
Blindness Diabetes
Eye Turn(Strabismus) High Blood Pressure
Lazy Eye(Amblyopia) Stroke
Glaucoma Thyroid Disease
Cataracts Other Inheritied Disease
Macular Degeneration Retinal Detachment Disease



How Often Do You Smoke/Use Tobacco Products?
How Often Do You Consume Alcohol?

Do You Have? Hepatitis HIV


To view the documents, please click the blue underlined links below then check the checkbox to agree.

* HIPAA & Patient Responsibilities
Click here to View the HIPAA Agreement
I have read and agree to the HIPAA Agreement

* Return Policy
Click here to View the Return Policy
I have read and agree to the Return Policy

Retinal Imaging (Optional)
By checking this checkbox below you Agree to the $25 copay for the Retinal Imaging.

Click here to View Retinal Imaging
I have read and agree to the $25 copay for the Retinal Imaging

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