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

*This field is required

Preferred Contact Method

Birthday

SSN

*This field is required

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Marital Status

Misc/Guardian

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Eye History

Do you currently have any of these eye symptoms?

Do you currently take any of these medications?

Last Eye Exam

*This field is required

By Doctor

Primary Vision Correction

*This field is required

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Contacts worn in the past

Cleaner

Disposal

Wear Time

Day/week

Hours worn comfortablly

Medical History:

Medications No Medications

*This field is required

Over the Counter Medications

Vitamins

Drug allergies

*This field is required

Pharmacy preference

*This field is required

Height:
Feet

*This field is required

inches

*This field is required

Weight:
pounds

*This field is required

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

*This field is required

Last Visit

Reason

Pregnant or Nursing

*This field is required

Recent Tetanus Shot

Family Medical History

*Required

Unknown Family History

Does anyone in your family have any medical conditions?

Family Eye History

*Required

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

Unknown Family History

Macular Degen

Glaucoma

Retinal Detach

Cataracts

Lazy/Crossed Eye

Review Of Systems

*Required

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

*Required

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

Acknowledgment of Notice of Privacy Practices

*Click here to view our HIPAA Privacy Policy*

The law requires that Doctor's Eye Clinic make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge one of the following:

I have read or had explained to me Doctor's Eye Clinic's Notice of Privacy Practice and agree to continue my care with Doctor's Eye Clinic under said terms.

Or

I was given the opportunity to read Doctor's Eye Clinic's Notice of Privacy Practice and did not wish to read it, but wish to continue my care with Doctor's Eye Clinic under the terms of Doctor's Eye Clinic's privacy policies.

Or

I have read or had explained to me Doctor's Eye Clinic's Notice of Privacy Practice and DO NOT wish to continue my care with Doctor's Eye Clinic under said terms.

I HAVE READ AND UNDERSTAND THIS FORM AND I AM SIGNING IT VOLUNTARILY:

Name of Patient:

Date:

Signature of Patient or Patient's Representative:

Relationship to Patient:

Name, Relation, Address, and Phone Number of those you authorize our office to release your private health information: