Online Patient Forms

Patient Information

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

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

Marital Status

Other information, (Ex: Guardian name)

Emergency Contact Name

Emergency Contact Phone

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 Vision Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

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 Medical Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

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!

General

Skin conditions

Illness or pain

Respiratory conditions

Muscular system disorders

Mental disorders

Endocrine system disorders

Blood / Lymphatic disorders

Nervous system conditions

Reproductive system disorders

Urinary conditions

Digestive system conditions

Cardiovascular conditions

Please list ALL medications you are taking

*This field is required

Are you allergic to any medications?

*This field is required

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Previous Eye Doctor

Last Visit

Have you ever been diagnosed or had any of the following?

Primary Vision Correction

Type of contact lenses, if any

Family Medical History

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

High Blood Pressure

*This field is required

Diabetes

*This field is required

Thyroid

*This field is required

Cancer

*This field is required

High Cholesterol

*This field is required

Heart Conditions

*This field is required

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

Other Eye Disease

Habits

Do you Smoke?

Do you drink alcohold daily?

Do you use recreational drugs?

Referral Information

How did you hear about us?

If other or friend/family referral, who?

Office Policies Agreement

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

Please ADD the above numbers together.