Online Patient Form

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

Demographics


Patient Information
TitleFirstLastMISuffixNicknamePronoun
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/GuardianDrivers License #



Medical Insurance

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:
Sex:
Address:
City: State: Zip:
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:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Insurance

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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary 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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Other

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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History



Nickname
Suffix MI Last First Title




Sex:
DOB:


Zip: City:
Address:
State:


Work #:
Email: Cell #: Phone #:


Occupation:
Employer:


Spouse or Legal Gaurdian:
Doctor: Last Eye Exam:


PRIMARY CARE PHYSCIAN: Last Visit:


Medical Insurance:
Vision Insurance:
FAMILY MEDICAL HISTORY



Thyroid Disease Heart Disease Glaucoma Blindness


Unknown family history
None Lupus Macular Degeneration Cataract


Other:
High Blood Pressure Retinal Detachment Cross Eyes


Arthritis Cancer Diabetes


Do you have any allergies to medications?
If yes, please list:
List all medications you are currently taking:


Pharmacy
Injuries, Surgeries, Hospitalization



Are you sensitive to light?
Pregnant Or Nursing


If yes, How old is your current pair of glasses?
Do you wear glasses?

Do you wear contact lenses?
Type of CLs worn in past:
Are you interested in contact lenses?
Blurred Vision
Thyroid Macular Degeneration
Diabetes
Loss of Vision
Cancer Glaucoma
High Blood Pressure
Double Vision
Arthritis Pain
High Cholesterol
Redness
Anemia Headaches
Dizziness
Crossed Eyes
Anxiety / Depression Excessive Tearing
Stroke
Lazy eye
Sinus Congestion Dryness
Seizure
Eye Surgery
Emphysema Itching / Burning
Migraine
Cataract
None Mucus Discharge
Spots
Retinal Detachment

Other Eye Injuries
Night Blindness

Flashes / Floaters
Eye Infection / Redness
Asthma
PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid
PATIENT OCULAR HISTORY: Injuries, Infections, Surgeries, Diseases


If you checked a box above or have a condition not listed, please explain:



Amount
How Long Type Tobacco


Amount
How Long Type Alcohol

Amount
How Long Type Illegal Drugs

STD
Syphilis HIV
Hepatitis
Gonorrhea
Have you ever been exposed to or infected with:

Referred by?

Hobbies:

Submit Data