Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian		Drivers License #

Is the Billing Address Different?

Billing Information

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Copy Address From Above
Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Vision Insurance

Primary Vision

Insurance Information

Insurance Name:	None AARP Aetna BlueCrossBlueShield Cigna Davis Vision Emblem EYEMED Vision Care GHI Medicare Tlc Laser Service UnitedHealthCare Vision Service Plan
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 Vision

Insurance Information

Insurance Name:	None AARP Aetna BlueCrossBlueShield Cigna Davis Vision Emblem EYEMED Vision Care GHI Medicare Tlc Laser Service UnitedHealthCare Vision Service Plan
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 Insurance

Primary Medical

Insurance Information

Insurance Name:	None AARP Aetna BlueCrossBlueShield Cigna Davis Vision Emblem EYEMED Vision Care GHI Medicare Tlc Laser Service UnitedHealthCare Vision Service Plan
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 Information

Insurance Name:	None AARP Aetna BlueCrossBlueShield Cigna Davis Vision Emblem EYEMED Vision Care GHI Medicare Tlc Laser Service UnitedHealthCare Vision Service Plan
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:

History

Vision History

Date of Last Eye Exam:

1 year 2 years 3 years Other

Date of Last Dilation

If Student, Grade

Do You Feel A Change Is Needed To See Clearly at:

Distance

Yes

No

Near

Yes

No

Do You Experience Any:

Eye Strain

Headache

Floaters

Spots

Have You Ever Received Visual Training (Eye Exercises)?

Yes

No

Do You Currently Wear Contact Lenses?

Yes

No

If Not, Why Did You Quit?

No

Are You Interested In A Contact Lens Evaluation?

Yes

No

Laser Vision Correction?

Yes

No

General Health History

Have You Ever Had Or Have:

Seasonal Allergies	Skin Conditions	High Blood Pressure	Diabetes
Auto Immune Disease	Allergies To Any Medications	Surgery	High Cholesterol
Drug Sensitivity	Cancer	Asthma	Thyroid Disease
Heart Disease

  Other Please Describe:

Are You Taking Any Medications / Supplements? (Birth Control Included)

Are You Pregnant?

Yes

No

Breast Feeding?

Yes

No

History Of Substance Abuse?

Yes

No

Cigarettes / Tobacco?

Yes

No

Drink Alcohol?

Yes

No

Date of last general medical exam

Physician

Ocular History

Have You Ever Had Or Have:

Eye Injury

Glaucoma

Eye Surgery

Macular Degeneration

  Other Please Describe:

Family Health History

	Blindness			Cataracts			Retinal Detachment			Diabetes
	Eye Disease			Glaucoma			Macular Degeneration			Heart Disease
	Hypertension

  Other Please Describe:

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