Online Patient Form
Click here to return to the previous website.
After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Widowed
Employer / School Name
Misc/Guardian
Billing Information
Is The Billing Address the Different?
Yes
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Primary
Insurance Information
Insurance Name:
None
AARP Medicare Supplement
AETNA Health Inc.
All Savers
Ambetter with Superior
Assurant Health
BCBS Medicare Advantage
BlueCross Blue Shield Federal
BlueCross/ BlueShield
Care Improvement Plus
CIGNA
Davis Vision
EyeMed
EYETOPIA
GEHA
Golden Rule
Health Comp
Humana
Humana Comp Benefits
Humana/MyCompBenefits/VCP
LIONS CLUB
Medicare
Mountain States Administrative Services
Mutual of Omaha
New Insurance
NOT ACTIVE
OSCAR
Palmetto GBA Railroad Medicare
PHCS
Principal Financial Group Claims
Scott & White Insurance
SELF PAY
Spectera Eyecare Networks
Superior Vision
Supplemental Plan
TML IEBP
Tricare East Region
TriWest
UMR
Unicare
United Healthcare and Pacificare PPO& HMO
United Healthcare Shared Services
UNITED HEALTHCARE VISION
VSP
WellMed Networks Inc.
WPS/Tricare
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:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Secondary
Insurance Information
Insurance Name:
None
AARP Medicare Supplement
AETNA Health Inc.
All Savers
Ambetter with Superior
Assurant Health
BCBS Medicare Advantage
BlueCross Blue Shield Federal
BlueCross/ BlueShield
Care Improvement Plus
CIGNA
Davis Vision
EyeMed
EYETOPIA
GEHA
Golden Rule
Health Comp
Humana
Humana Comp Benefits
Humana/MyCompBenefits/VCP
LIONS CLUB
Medicare
Mountain States Administrative Services
Mutual of Omaha
New Insurance
NOT ACTIVE
OSCAR
Palmetto GBA Railroad Medicare
PHCS
Principal Financial Group Claims
Scott & White Insurance
SELF PAY
Spectera Eyecare Networks
Superior Vision
Supplemental Plan
TML IEBP
Tricare East Region
TriWest
UMR
Unicare
United Healthcare and Pacificare PPO& HMO
United Healthcare Shared Services
UNITED HEALTHCARE VISION
VSP
WellMed Networks Inc.
WPS/Tricare
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:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
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
Vision Reason
No complaints - Wellness check
New glasses Rx
New Contact Lens Rx
Lasik Consult
Medical Reason
Diabetic Evaluation
Hypertension Evaluation
Glaucoma Evaluation
Cataract Evaluation
Dry Eye Evaluation
SLE Evaluation
Allergy Evaluation
Red Eye Evaluation
Other
Medical Symptoms
Blurred far vision
Blurred near vision
Itching
Burning
Tearing
Discharge
Redness
Irritation
Dryness
Pain
Eyelid Problems
Floaters
Flashes of light
Glare/Halos
Double vision
Light Sensitivity
Blind spots
Headaches
Eye fatigue
Medical History
Referred By:
Google
Insurance
Friend/Family
Website/Internet
Walk-by/Drive-by
Mail Out
Other
Referring Doctor:
Dr. John Branch
Dr. Loren Fisher
Dr. Elizabeth Neal
Other
Family Patients:
Hobbies:
Interested In Contact Lenses?
Yes
No
Maybe
Other
Ever Worn Contact Lenses?
Yes
No
Other
Type of CLs worn in past:
Never Worn
Soft
Soft Toric
Soft Monovision
Soft Bifocals
Gas Permeables (RGPs)
Gas Permeable (RGPs) - Monovision
Gas Permeables (RGPs) - Bifocals
Gas Permeables (RGPs) - Toric
Unknown
Soft 1 Day disp
Soft 1 month disp
Soft 2 week disp
Other
Back up specs for cls?
Yes
No
Other
Primary Vision Correction:
None
Contact Lenses
Single Vision Glasses
Bifocals
Progressive (No Line Bifocal)
Trifocals
SV Distance
SV Reading
Other
Sunspecs?
Yes
No
Other
Computer glasses?
Yes
No
Other
Problems with glare?
Yes
No
Other
Interested in Laser Vision Correction?
Yes
No
Maybe
Other
Medical Eye History
None
Unremarkable
Abrasion
Blepharoplasty
Blind Eye
Cataracts
Conjunctivitis
Dry Eye Syndrome
Floaters
Eye Surgery
Foreign Body Removed from Eye
Glaucoma
Infection
Lazy Eye (Amblyopia)
Macular Degeneration
Ptosis
Retinal Detachment
Strabismus
Lasik
PRK
Other
Eye Meds:
None
Unknown Allergy
Unknown Antibiotic
Unknown Steroid
Acular
Artificial Tears
Betoptic-S .25%
Betoptic .5%
Betagan
Erythromycin
FML
FML Forte
Gentamicin
Neosporin
Polytrim
Pred Mild
Pred Forte
Pataday
Patanol
Timoptic .25%
Timoptic .5%
Tobradex
Vigamox
Voltaren
Xalatan
Zymar
Zaditor
Pazeo
Systane Balance
Systane Complete
Erythromycin
Other
Last Eye Doctor:
Unknown
Dell M.D.
Eyemasters
Howerton M.D.
Henderson M.D.
Jacobs O.D.
McNabb M.D.
Seargent M.D.
Treadwell O.D.
Walters M.D.
Sorrenson, O.D.
Hammond, O.D.
Wasser, O.D.
Target Dr.
Wal-Mart Dr.
Other
Primary Care Physician:
Unknown
Dr. Elizabeth Neal
Dr. Loren Fisher
Other
Systemic Meds:
Medical History
Immediate Family Med History:
None Known
Unremarkable
Arthritis
Asthma
Cancer
Diabetes I
Diabetes II
Hypertension
Hypercholesterolmia
Heart Dx
Thyroid Dysfunction
Other
Family Eye History:
None Known
Unremarkable
Blindness
Cataracts
Glaucoma
Lazy Eye (Amblyopia)
Macular Degeneration
Retinal Detachment
Other
Drug Allergies:
No Known Drug Allergies
Aspirin
Erythromycin
Iodine
Penicillin
Sulfa
Codeine
Other
NOTES/SOCIAL HISTORY
Review of Systems
General:
None
Fatigue
Fever
Loss of Appetite
Weight Gain
Weight Loss
Developmental Disorders
Other
Ear/Nose/Throat:
None
Neck Problems
Sinus Problems
Sore Throat (Recent)
Headache
Morning Headaches
Migraine Headache
Cluster Headache
Hearing Loss
Tinnitus
Congestion
Dry throat / mouth
Sleep Apnea
Other
Skin:
None
Acne
Lupus
Dermatitis
Eczema
Psoriasis
Rosacea
Skin Cancer
Itching
Other
Cardiovascular:
None
Congestive Heart Disease
Cardiovascular Disease
High Cholesterol
Hypertension
Arrhythmia
Heart Murmur
Heart Palpitation
Chest Pain
Arteriosclerosis
Coagulation Disorder
Mitral Valve Prolapse
Low Blood Pressure
Other
Respiratory:
None
Asthma
Cancer: lung
Sleep Apnea
Sarcoidosis
COPD
Emphysema
Pneumonia
Bronchitis
Shortness of breath
Wheezing
Other
Musculoskeletal:
None
Arthritis
Osteoporosis
Fibromyalgia
Osteoarthritis
Muscular Dystrophy
Lupus
Decreased range of motion
Muscle cramps
Pain/tenderness
Stiffness
Swelling
Weakness
Other
Psychiatric:
None
Attention Deficit Disorder
Anxiety
Brain Damage (trauma)
Panic Attacks
Alzheimer's Disease
Bi-polar
Depression
Insomnia
Obsessive/Compulsive
Paranoia
Suicidal
Violence
Other
Gastrointestinal:
None
Acid Reflux
Crohn's disease
Gastric reflux (GERD)
IBS
Ulcer
Gall bladder problems
Jaundice
Hepatitis
Sarcoidosis
Cancer: colon
Cancer: Liver
Other
Endocrine:
None
Crohn's disease
Diabetes Type 1
Diabetes Type 2
Diabetes Suspect
Hypothyroid
Hyperthyroid
Gout
Hormone Replacement Therapy
Other
Blood/Lymph:
None
Anemia
Hx of Significant Blood Loss
Hematologic Disorder
Sickle Cell Disorder
Breast Carcinoma
Lymph Node Disease
Temporal Arthritis
Cuts slow to clot
Easy bruising
Other
Neurological:
None
Multiple Sclerosis
Seizure Disorder
Parkinson's Disease
Brain Tumor
Bells Palsy
Dyslexia
Headache
Balance problems
Vertigo
Tremors
Changes in senses
Dementia
Memory problems
Muscle weakness
Numbness, paralysis
Personality changes
Speech problems
Other
Genitourinary:
None
Amenorrhea
Menopause
Impotence
Jaundice
Uterine Cancer
Prostate Cancer
Kidney Stones
Pregnant
Nursing
Syphilis
Prostate Problems
Bladder Infections
STD- herpetic
STD- chlamydia
Other
Immune:
None
Seasonal allergies
Environmental allergies
Food allergies
Drug allergies (please specify)
Sjogren's syndrome
AIDS
Herpes Simplex
HIV Simplex
Mononucleosis
Tuberculosis
Cytomegalovirus Infection
Herpes Zoster
Lyme Disease
Sarcoidosis
Syphilis
Hives
Itching
Mild allergy symptoms
Severe allergy symptoms
Swelling
Other
Submit Form