Online Patient Form

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

Demographics


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 Vision Insurance

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:
SSN:
Employer/School:

Secondary Vision Insurance

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:
SSN:
Employer/School:

Primary Medical Insurance

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:
SSN:
Employer/School:

Secondary Medical Insurance

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:
SSN:
Employer/School:

Medical History


Please choose from the menu options or type in multiple items/your own text. Thank you!

Review of Ocular System

Please list any eye diseases you currently have and any eye surgeries you've had:
Please list any eye drops or eye medications that you use:
Last Eye Exam: By Doctor:

Family Ocular History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Crossed / Lazy:

Previous Vision Correction

Primary Vision Correction:
Planning to get new glasses? Do you have prescription sunglasses?

If you wear soft contacts, what brand do you currently wear?:
Wear Time: Cleaner: Disposal:

Review of Systems

General: (ex. Fever, weight loss, weight gain, fatigue)
Ear/Nose/Throat: (ex. Allergies, Sinus, Cough, Dry Mouth/Throat)
Cardiovascular: (ex. High BP, Heart Surgery, Vascular Disease)
Respiratory: (ex. Asthma, Bronchitis, Emphysema, COPD)
Genital/Kidney/Bladder: (ex. Kidney Stones, Frequent Urination, Impotence)
Muscles/Bones/Joints: (ex. Athritis, Joint Pains, Head or Neck Injury)
Skin: (ex. Growths, Rashes, Acne)
Neurological: (ex. Headaches, Migraines, Seizures)
Psychiatric: (ex. Depression, Anxiety, Insomnia)
Endocrine: (ex. Thyroid, Diabetes)
Blood/Lymph: (ex. Anemia, Cholesterol, Bleeding Problems)
Gastrointestinal: (ex. Diarrhea, Constipation, Ulcer, Reflux)
Immune: (ex. Seasonal Allergies, Rheumatoid, AIDS, Lupus)

Medical History

If you answered YES to any of the above, please list your current medical conditions:


Please list any Injuries, Surgeries, Hospitalizations:
Pregnant Or Nursing: Recent Tetanus Shot:
Primary Care Physician: Last Visit: Reason:

Please list all prescription medications you take:


Please list any medications which you are allergic to:
Please list any over-the-counter meds you take regularly:
Please list any vitamins that you take regularly:

Family Medical History

Please list any medical conditions that run in your family:

Social History

Occupation: Hobbies: STD's:

Tobacco Use: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drugs: Type: How Long:

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