Online Patient Form

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After completing all the forms, please submit your data on the final tab. Thank you!

Demographics

Fields marked with a * are required.
TitleFirst*Last*MISuffixNickname
Address:
City: State/ZipCode
Home Phone*: Work Phone:
Other Phone: Alerts:
Cell Phone*: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer / School Name
Misc/Guardian

Primary Medical Insurance

Insurance Name:
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

Insurance Name:
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:

Primary Vision Insurance

Insurance Name:
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

Insurance Name:
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 History

Do you have any of these eye symptoms?:
Do you take any eye medications?:

Last Eye Exam:
Primary Vision Correction: Do you have backup glasses?: Want new glasses?:
Type of CLs worn in past: Wear Time: Cleaner: Disposal:

Family Eye History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Crossed/Lazy Eye:

Review of Systems

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

Pregnant Or Nursing: Recent Tetanus Shot:

Primary Care Physician*: Last Visit: Reason:
Pharmacy Preference*:

Height*: ft. in.
Weight*:

Medications: No MedsAllergies: No Known Drug Allergies

Vitamins: Over The Counter Meds:

Have you had any injuries, surgeries, or hospitalizations?:

Family Medical History

Please describe any medical conditions that occur in your family, along with the relationship of the family member.

Social History

Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drugs: Type: How Long: STD's?:

Race: Ethnicity: Preferred Language:

Submit Data

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Acknowledgement of Notice of Privacy Practices

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:


OR


OR


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:
1.
2.
3.
4.