Patient information

Online Patient Forms

Glaucoma

Macular Degeneration

Retinal Detachment

Cataracts

Lazy/Cross Eye

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Secondary Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

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Vision History

What is the main Reason for your visit?

Last Eye Exam

Doctor

Have you had any Eye Injuries/ Surgeries? Please describe

Other Eye History

Do you use any Prescription eye drops/ Over-The-Counter eye drops?

Medical History

Please Describe any Major Injuries or Surgeries you have had

Other Medical History

Medications No Medications

Allergies No Known Drug Allergies

Vitamins/ Supplements

Primary Care Provider

Last Physical Exam

Pregnant or Nursing

	Your self	Mother	Father	Sibling	None
Diabetes

Year Diabetes was diagnosed

Last HbA1c

Social History

Hours of Screentime/ Hobbies/ Personal Information