Online Patient Forms

Patient Information

Upload Driver Lisc [front]:

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Upload Driver Lisc [back]:

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First Name

*This field is required

Last Name

*This field is required

Nickname

Birth Sex

Male Female

*This field is required

Address

*This field is required

Apt/Suite #

City

*This field is required

State

*This field is required

Zip Code

*This field is required

Cell Phone

*This field is required

Home Phone

*This field is required

Preferred Contact Method

Birthday

*This field is required

SSN

Occupation

*This field is required

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

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:
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Back of the ins card:
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Insurance Name:

*This field is required

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:

Primary Vision 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:

*This field is required

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!

Eye History

Reason for Visit

*This field is required

Secondary Reason

Do you currently have any of these symptoms?

*This field is required

Do you currently take any of these medications?

*This field is required

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

Medical History

Medications

*This field is required

No Medications

Over the Counter Medications

*This field is required

Vitamins

*This field is required

Drug allergies

*This field is required

No Known Drug Allergies

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Pregnant

Breast Feeding

Family Medical History

Do you or anyone in your family have any of these medical conditions?

Unknown family history

Diabetes

*This field is required

Type

Year Diabetes diagnosed

HbA1C

High Blood Pressure

*This field is required

Describe

High Cholesterol

*This field is required

Describe

Thyroid

*This field is required

Describe

Heart Conditions

*This field is required

Describe

Cancer

*This field is required

Describe

Family Eye History

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

Macular Degeneration

*This field is required

Glaucoma

*This field is required

Retinal Detachment

*This field is required

Cataracts

*This field is required

Lazy/Crossed Eye

*This field is required

Review Of Systems

General

*This field is required

Skin

*This field is required

Ear/Nose/Throat

*This field is required

Respiratory

*This field is required

Musculoskeletal

*This field is required

Psychiatric

*This field is required

Endocrine

*This field is required

Blood/Lymph

*This field is required

Neurological

*This field is required

Immune

*This field is required

Genitourinary

*This field is required

Gastrointestinal

*This field is required

Cardiovascular

*This field is required

Social History

Hobbies

STD

Smoking Status

*This field is required

Type

How long

Alcohol Use

*This field is required

Type

How long

Illegal Drug Use

*This field is required

Type

How long

Race

Ethnicity

Preferred Language

Office Policies Agreement

Please review the following agreement. Sign below to acknowledge and attach your signature to the final PDF.

The OSDI (Ocular Surface Disease Index) questionnaire is a simple screening tool that helps your doctor evaluate the comfort of your eyes and identify signs of ocular surface disease, including dry eye. We encourage you to complete it before your appointment, please click the link below to open and print it out to bring with you on the day of your visit. If you prefer not to complete it in advance, you may fill it out in the office-simply let one of our staff members know when you arrive.

View OSDI (Ocular Surface Disease Index) questionnaire

Please ADD the above numbers together.