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!

Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:

City:		State:		Zip Code:

Home Phone:		Work Phone:
Other Phone:
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
Misc/Guardian

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!

Reason for Visit:	Secondary Reasons:

Prescription Medications:

Over The Counter Medications:

Vitamins:

Please describe any injuries or surgeries you have had:

Primary Care Physician:

Last Visit:

Reason:

Height:	ft.	in.
Weight:	lbs.

Pregnant Or Nursing:

Recent Tetanus Shot:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:

Last Eye Exam:

By Doctor:

Do you ever feel your eyes?:		Do you have to blink often?:
Do you use artificial tears?:		Are your eyes ever red?:

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

Acknowledgment of Notice of Privacy Practices

The law requires that True Vision make every effort to inform you of your rights related to your personal health information. By signing below, you acknowledge one of the following:

	I have read or had explained to me True Vision's Notice of Privacy Practices and agree to continue my care with True Vision under said terms.

	I was given the opportunity to read the True Vision's Notice of Privacy Practices and did not wish to read it, but wish to continue my care with True Vision under the terms of True Vision's Notice of Privacy Practices.

	I have read or had explained to me True Vision's Notice of Privacy Practices and DO NOT wish to continue my care with True Vision under said terms.

I have read and understand this form, I am signing it voluntarily.

Signature: Date:

If you would like us to release your private health information to any of the following individuals, please check the boxes below:

Spouse Parent(s) Children Other: