Patient Form

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When you are finished, be sure to hit the submit button at the bottom of the form.
If you have any questions, please call us at (813) 854-9000.
We can always change the data in the office if you are unsure about what to enter in any of the fields.

Demographic Information

Title	First	Last	MI	Suffix	Nickname

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

Billing Information Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

Primary Insurance Information
If your insurance is not listed, please type it into the insurance policy group field. Thank you!

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
If your insurance is not listed, please type it into the insurance policy group field. Thank you!

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
If your insurance is not listed, please type it into the insurance policy group field. Thank you!

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 and your own text. Thank you!

Referred By:
Referring Doctor (OPTIONAL):
Primary Vision Correction:

Spend hours on a computer at work?
Drive at night?
Diffuculty reading?
Have Sunglasses with UV Protection?
Ever Worn Contact Lenses?
Interested In Contact Lenses?
Back up glasses for contacts?
Interested in LASIK?

Last Eye Exam:
Primary Care Physician:

Eye Hx: Conditions, Infections, Injuries, Surgeries

Med Hx: (Diabetes,HTN,Seizures,Thyroid,Arthritis)

If YOU are diabetic:

When were you diagnosed?
Last HBA1c:
Last fasting blood glucose reading:

Medications:

Drug Allergies:

Family History:

	Mom	Dad	Sibling	Grandparent
Glaucoma:
Macular Degeneration:
Eye Turn/Lazy Eye:
Diabetes:
Hypertension:
Cancer:

Race (OPTIONAL):
Ethnicity (OPTIONAL):
Smoking Status:

Preferred Language:

Review of Systems
Please choose from the menu options or select "Other" to type in multiple items and your own text. Thank you!

Do you currently have any of these problems?

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

Submit Data
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