Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Items marked with * are required.

Patient Information

Title	First*	Last*	MI	Suffix	Nickname

Address:*

City:*	State:*	Zip Code:*

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
		Emergency Contact Name / Phone Number:

Billing Information

Is The Billing Address the Same? Yes

Title	First*	Last*	MI	Suffix

Address:*

City:*	State:*	Zip Code:*
Home Phone:*
Work Phone:

Medical History

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

Do you wear sunglasses?:	Yes	No
Do you use a computer?:	Yes	No -	Desk	Lap -	Hours Per Day:

Eye strain, neck ache, glare, other discomfort with computer use?:

Yes

Ocular Surgeries*

Surgeries	Surgery Dates	Surgeon

Ocular Medications*

Ocular Medications	Amount	Eye	Dosage

Medications*

Medications

Drug Allergies*

Drug Allergies

Surgeries*

Surgeries	Surgery Dates

Eye History

Glaucoma*	Yes	No
Macular Degen*	Yes	No
Cornea*	Yes	No
Retina*	Yes	No
Lazy Eye*	Yes	No
Crossed Eyes*	Yes	No
Lid Infection*	Yes	No
Blindness*	Yes	No
Color Blindness*	Yes	No
Tumors*	Yes	No
High Risk Medications*	Yes	No
Other*	Yes	No

Family Eye History

Glaucoma*	Yes	No
Macular Degen*	Yes	No
Cornea*	Yes	No
Retina*	Yes	No
Lazy Eye*	Yes	No
Crossed Eyes*	Yes	No
Lid Infection*	Yes	No
Blindness*	Yes	No
Color Blindness*	Yes	No
Tumors*	Yes	No
High Risk Medications*	Yes	No
Other*	Yes	No

Review of Systems

Ear/Nose/Throat*	Yes	No
Blood/Lymph*	Yes	No
Genital/Kidney/Bladder*	Yes	No
Cardiovascular*	Yes	No
Respiratory*	Yes	No
Gastrointestinal*	Yes	No
Endocrine*	Yes	No
Neurological*	Yes	No
Muscles, Joints*	Yes	No
Psychiatric*	Yes	No

Family Review of Systems

Ear/Nose/Throat*	Yes	No
Blood/Lymph*	Yes	No
Genital/Kidney/Bladder*	Yes	No
Cardiovascular*	Yes	No
Respiratory*	Yes	No
Gastrointestinal*	Yes	No
Endocrine*	Yes	No
Neurological*	Yes	No
Muscles, Joints*	Yes	No
Psychiatric*	Yes	No

Health Info

Primary Care Physician:		Last Physical:
Pregnant/Nursing:*

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

Race:
Ethnicity:
Preferred Language:

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Preferred Method of Retinal Evaluation

Here at Pearl Optical we always recommend a comprehensive ocular health examination. This type of exam allows the doctor to evaluate not only the ocular health but also other systemic health problems that can begin with signs in the back of the eyes that are not noticeable without one of these methods. The two methods to properly perform a comprehensive ocular health examination is through dilation or digital retinal imaging. Without one of these two methods a complete ocular health examination is not possible anywhere.

Dilation involves the insertion of eye drops that enlarges the pupils to allow for the doctor to shine a bright light inside the back of the eye and evaluate the structures inside the eye. After insertion of eye drops it is normal to experience some stinging/burning sensation. It typically takes between 20-30 minutes for dilation to take effect but can be longer for some patients and will cause blurry vision and sensitivity to light. These side effects typically last between 4-6 hours but can last longer for some patients.

Digital retinal imaging allows for the evaluation of the inside structures of the eyes without the use of dilation drops. This procedure is quick, easy, and painless. It also allows for photo documentation that will be maintained in your record to monitor for any progression and/or changes over time. This procedure is not included in our regular examination fee and is probably not covered by your vision care insurance unless a medical health issue is present or found. We keep our fees low because we would like our patients to take advantage of this service. The total fee for this procedure is $39.00. If you choose to have retinal imaging performed the doctor will show and discuss the results with you today.

I have read, understood, and been provided with the information above.

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