Online Patient Forms

Patient Information

Upload Driver Lisc [front]:

Front of the card preview

Upload Driver Lisc [back]:

Back of the card preview

First Name

*This field is required

Last Name

*This field is required

Nickname

Birth Sex

Male Female

*This field is required

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

Billing Information

Is The Billing Address Different?

Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

Apt/Suite:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Relationship Options:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Secondary Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Tertiary Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Vision Plan

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

Plan Name:

Plan ID:

Plan Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Please choose from the menu options or select the option to type in your own text. Thank you!

Ocular/Medical History

Reason for Visit

Date of Last Eye Exam

Please describe any history of current eye problems or conditions/prior surgeries:

Do you use any prescription eye drops?

Do you use any over the counter eye drops?

Does your family have a history of these eye conditions?

Family History Unknown

	Parent	Sibling	Paternal Grandma	Paternal Grandpa	Maternal Grandma	Paternal Grandpa	None
Cataracts
Glaucoma
Macular Degeneration

Retina

Other Eye Conditions in Family Please describe

Review of Systems

Constitutional

Frequent Fevers

Changes in Weight

Overweight

None

Psychiatric

Depression

Anxiety

Overweight

Bipolar

None

Gastrointestinal

Constipation

Diarrhea

Crohn's

Reflux/GERD

None

Respiratory

Asthma

COPD

Oxygen Use

None

Bones/Muscles

Arthritis

Fibromyalgia

Muscle Disorder

Gout

Back Pain

Cane

Walker

Wheelchair

None

Genitourinary

Bladder Condition

Kidney Problems

Prostate Issues

None

Skin

Skin Condition

None

Ear/Nose/Throat

Allergies

Sinusitis

Vertigo

Hearing Aids

None

Blood/Lymph

Anemia

Bleeding Disorder

None

Vascular

Diabetes

Heart Condition

Blood Pressure

Cholesterol

None

Immune

HIV

AIDS

Hepatitis

None

Endocrine

Thyroid

Para Thyroid

None

Cancer

None

List medications you take

Are you allergic to any medications?

List major illnesses/injuries/surgeries

Primary Care Physician

Last Visit

Preferred Pharmacy

Social History

Do you Drive?

Yes

Race

Ethnicity

Preferred Language

Smoking Status

Alcohol Use

Illegal Drug Use