Online Patient Form

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

Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN (Last 4 Digits) 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?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary Insurance Information

Insurance Name:
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

Insurance Name:
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 or your own text. Thank you!

Reason for Visit: Secondary Reasons:

Medications: No Meds Used Over The Counter Medications:
Vitamins: Drug Allergies: No Known Drug Allergies
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot:

Family Medical History

Unknown family history

Diabetes: Type: Year Diagnosed: HbA1C:
High Blood Pressure: Describe:
High Cholesterol: Describe:
Thyroid Disease: Describe:
Heart Problems: Describe:
Cancer: Describe:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses?

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time: Days per week worn: Hours per day worn:

Family Eye History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye:

Review of Systems

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

Social History

Hobbies: STD's:

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

Race: Ethnicity: Preferred Language:


Authorization

I authorize the release of any medical or information necessary to process this
claim. I also request payment of government benefit to the party who accepts
assignment.
Initials:


I hereby authorize payment directly to FLOE Optometry for the
surgical and/or medical benefits. It is understood that any money received
from the above named insurance company is over and above my indebtedness
will be refunded to me when my bill is paid in full. I understand that I am
financially responsible for all charges not covered by this authorization.
Initials:


The dilating drops used in your eyes as part of the examination may blur your
vision and make it unsafe for you to drive. Please do not drive your car until
you are sure that the effect has worn off. The effect usually lasts four hours and
disposable sunglasses are available upon request. FLOE Optometry agrees to
provides its professional services by the doctor and employees to the patients.
FLOE Optometry reserves the right to select the doctor to perform the service
required in the best interests of its patients to which the undersigned patients
or guardian agrees.
Initials:


Signature: Date:

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