Online Patient Forms

Patient Information

First Name

*This field is required

Last Name

*This field is required

Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

Billing Information

Is The Billing Address Different?

Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

Apt/Suite:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Medical Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Relationship Options:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Secondary Medical Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Medical History

Please choose from the menu options or select the option to type in your own text. Thank you!

Reason for Visit

Secondary Reason

Medications

No Medications

Over the Counter Medications

Vitamins

Drug allergies

No Known Drug Allergies

Please Describe any Injuries or Surgeries you have had

Height & Weight

Feet

Inches

Pounds

Primary Care Physician

Last Visit

Reason

Other Specialist

Other Eyecare Specialist

Pregnant or Nursing

Recent Tetanus Shot

Eye History

Do you currently have any of these symptoms?

Do you currently take any of these medications?

Have you had any eye surgeries? Please describe

Last Eye Exam

By Doctor

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Days per week worn

Hours per day worn

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

Family Medical History

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

Unknown family history

Diabetes

Type

Year Diagnosed

HbA1C

High Blood Pressure

Describe

Thyroid

Describe

Cancer

Describe

High Cholesterol

Describe

Heart Problems

Describe

Family Eye History

Does anyone in your family have any of these eye conditions?

Macular Degeneration

Glaucoma

Retinal Detachment

Cataracts

Lazy/Crossed Eye

Office Policies and Agreements

Please review the following agreements. Sign below to acknowledge and attach your signature to the final PDF's.


Please ADD the above numbers together.