Online Patient Form

Click here to return to the the previous website.

After completing all the forms, please submit your data on the final tab. Thank you!

Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
Email Occupation
Birthday Employment Status Employed Full-Time Student Part-Time Student
Sex Male Female Employer/School Name
Marital Status Misc/Guardian
Primary Doctor
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
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:
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:
Employer/School:

Tertiary

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:
Employer/School:

Vision Plan 1

Insurance Information
Plan Name:
Plan ID:
Plan 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:
Employer/School:

Ocular/Medical History

Ocular/Medical History
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

   None   Parent   Sibling    Paternal
  Grandma		    Paternal
   Grandpa		   Maternal
  Grandma		   Maternal
  Grandpa
Cataracts                                                 
Glaucoma                                                 
Mac Degen                                                 
Retina:
Other Eye Conditions in Family:

Review of Systems

      Eyes                               Constitutional                Neurological                  Psychiatric
Loss of Vision     Frequent Fevers     Migraines     Depression
Blurred Vision     Changes in Weight     Seizures     Anxiety
Sudden Blindness     Overweight     Stroke     Bipolar
Halos     None     MS     PTSD
Blind Spots       Dementia     None
Double Vision          Gastrointestinal     Alzheimer's
Light Flashes     Constipation     Autism          Respiratory
Floaters     Diarrhea     Neuropathy     Asthma
Wavy Lines     Crohn's     ADD/ADHD     COPD
Itchiness     Reflux/GERD     Parkinson's     Oxygen Use
Dryness     None     None     None
Watery  
Styes          Bones/Muscles          Genitourinary          Skin
Crossed Eyes     Arthritis     Bladder Condition     Skin Condition
Lazy Eye     Fibromyalgia     Kidney Problems     None
Droopy Lid     Muscle Disorder     Prostate Issues
Glaucoma     Gout     None          Ear/Nose/Throat
Cataract     Back Pain       Allergies
Lens Implant     Cane          Blood/Lymph     Sinusitis
Retinal Condition     Walker     Anemia     Vertigo
Eye Injuries     Wheelchair     Bleeding Disorder     Hearing Aids
None     None     None     None
 
      Vascular          Immune          Endocrine          Cancer
Diabetes     HIV     Thyroid     
Heart Condition     AIDS     Para Thyroid     None
Blood Pressure     Hepatitis     None
Cholesterol     None
None

List major illnesses/injuries/surgeries:

List medications you take:   Are you allergic to any medications?
  

Social History

Do you drive?: Yes No

Race Ethnicity Preferred Language

Smoking Status:
Alcohol Use:
Illegal Drug Use:


Primary Care Physician: Last Medical Exam:
Preferred Pharmacy:

Final Step