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


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Medical History

EYE HISTORY:



Last Eye Exam:
Currently wear glasses?
Currently wear contacts?
Reason for today's visit

Have You Or A Family Member Experienced, Or Been Treated For, Any Of The Following? Check All That Apply:


Condition Yes No Family
Cataracts
Crossed Eye
Glaucoma
LASIK or RK
Lazy Eye
Macular Degeneration
Retinal Detachment

Are You Currently Experiencing, Or have Experienced, Any Of The Following? Check All That Apply:


Blurry Vision Near Distance
Burning
Discharge
Double Vision
Dryness
Excess Tearing / Watering
Eye Infection
Eye Pain Or Soreness
Floaters Or Spots
Halos
Headaches
Itching
Light Flashes
Light Sensitivity
Redness
Sandy Or Gritty Feeling

MEDICAL HISTORY:


Have You Or A Family Member Experienced, Or Been Treated For, Any Of The Following? Check All That Apply:


Condition Yes No Family
Aids / HIV
Allergies
Arthritis
Asthma
Blood / Lymph Disorder
Cancer
Diabetes
Ear, Nose, Throat Conditions
Gastrointestinal Conditions
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Lupus
Neurological Conditions
Psychiatric Disorder
Seizures
Skin Conditions
Stroke
Thyroid Dysfunction

Eye Meds:
Systemic Meds:
Drug or Seasonal Allergies:



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Patient Privacy Policy


Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

View HIPAA Patient Privacy Policy Form

Printed Name of Patient:
Signature of Patient/Guardian/Representative:

Patient Financial Responsibility


View Patient Financial Responsibility Form

Printed Name of Patient:
Signature: Date:

Assignment Of Benefits Authorization And Release Of Medical Information

Signature: Date:

** By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I accept has the same validity and meaning as my handwritten signature.