Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
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
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary Medical Insurance

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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Medical Insurance

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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Insurance

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:Spouse Child Other
Sex: Male Female
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!

Patient Medical History
What is your PRIMARY reason for choosing our office?
Referring Doctor:

Interested In Contact Lenses?
Ever Worn Contact Lenses?
Brand of contact lens worn in past:

Interested in Laser Vision Correction?

Eye History(Injuries, Surgeries, Glaucoma, Macular Degeneration, "Lazy Eye", Retinal Detachments, etc...):

Eye Medications:
Last Eye Exam:
Last Eye Doctor:
Last Wellness Check-up by a physician:
Primary Care Physician:
Allergies?:

Current Daily Medications:Medical/Health Conditions
(Pregnancy, Diabetes, Hypertension, Cancer, Heart Disease, etc...):
Family Medical History
(Heart Disease, Cancer or Diabetes?):
Family Eye History
(Glaucoma, Macular Degeneration, "Lazy Eye", etc...)

Anything else you would like us to know regarding your eyes or vision?:

Lifestyle


Patient Lifestyle Information
What is your professional environment?
How much time are you on a screen(Computer, Smartphone, iPad/tablet, TV)?
How much time do you spend driving at night on a weekly basis?
What type of outdoor activities do you participate in?
What are your indoor hobbies?
Personal Eyewear Style:
I prefer colors that are?

What did you like about your last pair of glasses?
What would you change about your last pair of glasses?

Submit Data

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