Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Fields marked with * are required

Patient Information


Title * First *Last MI Suffix Nickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
*Cell Phone: Preferred Contact Method:
SSN *Email
*Birthday Occupation
*Sex Male Female
Employer / School Name
Primary Doctor
How Did You Hear About Us?

Billing Information

Is The Billing Address the Same?
Title First Last MI Suffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

*Reason for Visit: *Any other reason for your visit?:

*Medications: No Meds Used *Eye Medications:
*Drug Allergies: No Known Drug Allergies

*Please describe any injuries or surgeries you have had:
NONE

Pregnant Or Nursing:

Review of Systems

*General: *Ear/Nose/Throat:
*Skin: *Cardiovascular:
*Respiratory: *Musculoskeletal:
*Psychiatric: *Gastrointestinal:
*Endocrine: *Blood/Lymph:
*Neurological: *Genitourinary:
* Immune:

Family Medical History

Unknown family history



*Diabetes: Family Member:
*High Blood Pressure: Family Member:
*High Cholesterol: Family Member:
*Thyroid Disease: Family Member:
*Heart Problems: Family Member:
*Cancer: Family Member:

Eye History

*Do you have any eye conditions or symptoms? (ie. dryness, redness, flashes/floaters, glaucoma, retinal disorders, macular degeneration, etc?)

Please describe:


Last Eye Exam: By Doctor:

*Primary Vision Correction:

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:


Family History of Ocular Diseases:

Glaucoma:
          		Cataracts:
          		Macular Degeneration:
          		Retinal Detachment:
          		Crossed / Lazy Eye:
   

Social History

Hobbies:

*Smoking Status: How Long:
* Alcohol Use:
*Illicit Substance: Type:

Submit Form

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Notice of Privacy Practices

View Notice of Privacy Practices Form

*Patient Signature: *Date:

Eyewear Policy

View Eyewear Policy Form

*Patient Signature: *Date:

Contact Lens Policy

View Contact Lens Policy Form

*Patient Signature: *Date:

Financial Policy

View Appointment Cancellation Policy Form

*Patient Signature: *Date: