Example Online Patient Form

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Please fill all fields out to the best of your ability and scroll all the way down to make sure you haven't missed anything. Thank you!


Patient Information
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Employer / School Name

Chief Complaints

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

Chief Complaint:
Reason for Visit:
Secondary Complaints:

Past Surgeries

Major Illnesses

Race: Ethnicity: Preferred Language:

Social History

Smoking Status Type: How Long:
Alcohol: Type: How Long:
Illegal Drugs: Type: How Long:

Tobacco Cesssation Counseling? Past Smoker? Quit Smoking When? Do you use chewing tobacco?

Marital Status: Engage in regular exercise? STD:

Medical History

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

Patient Medical History
General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:

Family Medical History
Eye Diseases:Relationship to Patient:
Color Defeciency:
Eye Tumors:
Macular Degeneration
Retinal Detachment
Systematic Diseases:Patient Notes:
Heart Disease:
High Blood Pressure:
Kidney Disease:
Thyroid Disease:

Patient Medical History
Primary Care Physcian: Last Visit: Reason For Visit:

Height:Ft.In.       Weight:Lbs.

Current MedicationsAllergy History:

Vitamins: Over The Counter Medications: Pregnant Or Nursing: Recent Tetanus Shot:


Blood Sugar: Date Blood Sugar was Taken:
HbA1C: Date HbA1C was Taken:

Visual History

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

Patient Eye Diseases
If yes, how long has this been a problem? Please briefly describe:
Color Blindness:
Eye Injuries:
Diabetic Retinopathy:
Glaucoma Suspect:
High Risk Medication:
Macular Degeneration:
Retinal Detachment:

Patient Current Eye Symptoms
If yes, please briefly describe:
Light Sensitivity:
Tired Eyes:
Eyelid Swelling:
Eye Pain or Soreness:
Foreign Body Sensation:
Infection of Eyelid:
Ptosis (Drooping Eyelid):
Sandy or Gritty Feeling:
Blurred Vision Distance:
Blurred Vision Near:
Distorted Vision:
Double Vision:
Flashes of Lights:
Floaters or Spots:
Fluctuating Vision:
Loss of Vision:

Additional Notes:

Review of Ocular System
Last Eye Exam: Doctor:

Primary Vision Correction: Do you have backup glasses? Do you want new glasses?

Type of CLs worn in past: Cleaner: Disposal: Wear Time:

Hours per Day: Days per Week:



Patient Ocular Information
Rate each of the following from 0-4, where 0=never, 1 = rarely, 2 = sometimes, 3 = often, 4 = always

Experienced the following?Limited in performing the following?Uncomfortable in the following?
Sensitivity to light? Reading? Windy conditions?
Gritty feeling? Driving at night? Low humidty?
Painful or sore? Computer use? Air conditioning?
Blurred vision? Watching TV?
Poor vision

Submit Data


I understand that The Eyecare Center of Salem (referred to below as "This Practice") will use and disclose health information about me.

I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.

I understand and agree that This Practice may use and disclose my health information in order to:
  • make decisions about and plan for my care and treatment;
  • refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment;
  • determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and
  • perform various office, administrative and business functions that support my physician’s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.
I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice's Notice of Privacy Practices in effect will be posted in waiting/reception area and available on the website at eyecarecenterofsalem.com.

I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.

By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices.

Financial Notice (ABN)

The patient's portion of charges is due at the time of service. There will be a service charge on all returned checks. Unpaid accounts will be forwarded to our collection agency. Payment from my insurance is to be paid directly to Eyecare Center of Salem, LLC. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.

By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices. Please check, sign and date that you have read, understand, and agree to the above, then click the submit data button to complete your online forms. Thank you!

Check: Patient Signature: Date:

After Completing All Forms Submit Data on Final Tab