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

Billing Information

Is The Billing Address the Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Vision Insurance Information

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance Information

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
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:

Over The Counter Medications:
Vitamins:

Please describe any injuries or surgeries you've had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing:

Family Medical History

Does anyone in your family have any of these medical conditions?:

Cancer: Type:
Diabetes:
Heart Disease:
Multiple Sclerosis:
Thyroid Disease:
Lupus:

Eye History

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

Family Eye History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Blindness:
Ocular Cancer: Keratoconus:

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:

Submit Form

Your protected health information (including but not limited to: name, date, address, diagnosis and treatment plan) may be shared in connection with your treatment with health care providers and insurance benefit providers. Under the Dept. of Health and human services privacy regulations (HIPAA), this office must obtain consent to do so. There is a complete privacy policy on file for your review if requested. I have been presented with the option of reading the office Privacy Policy and do hereby give consent to use of my/the patient's health information. Furthermore, in checking below this consent you also agree to pay expenses not covered by your medical insurance, or denied as a non-covered service.



Signature: Date: