Online Patient Form

Click here to return to the the previous website.

After completing all the forms, please submit your data on the final tab. Thank you!

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 Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer / School Name
Primary Doctor Misc/Guardian

Race: Ethnicity: Preferred Language:
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision

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:

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


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

Eye History

Reason for Visit:
Location: Severity: Quality: Duration:
Timing: Context: Modifying: Associated:

Secondary Reasons:
Duration: Quality: Severity: Location:
Associated: Modifying: Context: Timing:


Do you experience any of these eye problems?:
Eye Meds: Last Eye Exam: Doctor:


Have you experienced any of the following during the last week?

Painful/Sore Eyes: Blurred Vision: Eyes that are sensitive to light:
Eyes that feel gritty: Poor Vision:

Do you have problems with your eyes limiting you in performing any of the following during the last week?

Driving at Night: Reading: Working with a computer or bank machine (ATM):
Watching TV:

Have your eyes felt uncomfortable in any of the following situations during the last week?

Windy Conditions: Places or areas with low humidity (very dry): Areas that are air conditioned:


Primary Vision Correction:
Do you have back up glasses?: Do you want new glasses?:

Contact Lens Wearers Only

Type of CLs worn in past: Cleaner: Disposal:
Wear time: Days per week: Hours worn comfortably:

Family Eye History

Macular Degeneration: Cataracts:
Retinal Detachment: Glaucoma:
Crossed/Lazy Eye(s):

Medical History

Primary Care Physician: Last Visit: Reason:
Vitamins: Over The Counter:
Pregnant or Nursing: Recent Tetanus Shot:

Injuries, Surgeries, Hospitalizations:

Current Medications:

Review of Systems

General: Ear, Nose, Throat:
Respiratory: Cardiovascular:
Skin: Genital, Kidney, Bladder:
Psychiatric: Muscles, Bones, Joints:
Endocrine: Allergic/Immunologic:
Neurological: Gastrointestinal:
Blood/Lymph:

Family Medical History

Please list any medical conditions that may run in your family.


Social History

Occupation: Hobbies:

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

Submit Data


A DIGITAL IMAGE OF THE RETINA WILL BE PERFORMED ANNUALLY FOR EVERY PATIENT!

Retinal problems such as macular degeneration, glaucoma, retinal holes, retinal detachments
and diabetic retinopathy can now be seen without dilation for most patients and it is far easier
for the doctor to examine the eye with the digital image instead of looking through the eye with
a microscope which gives a very limited view. The time to evaluate the retina is instant, the
exam is painless and allows a 200 degree view of the entire internal health of the eye without drops.

Early detection is crucial! Without a thorough eye examination serious disease can be missed
such as: diabetes, retinal detachments or malignant tumors. All of these can lead to vision loss,
blindness or even death. The small fee is $39 and may be covered by your health insurance
company, if a medical condition is found.

A DIABETES RISK EVALUATION WILL BE PERFORMED FOR ALL PATIENTS OVER THE AGE OF 18!

As a leading cause of blindness, it is very important for us as your eye doctor to test for this
disease. Early detection is now available, and it is PAINLESS, QUICK and NON-INVASIVE.
A six second scan of the lens of you eye will show us your entire lifetime of blood sugar
control and it can tell us up to 7 years before diabetes complications start.

The small fee for the evaluation is $39. A discounted fee of $69 will apply when both tests are
performed. Please let us know if you have any questions regarding these important ocular evaluations.

Please Initial: