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!

Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:

City:	State:	Zip Code:

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
Guardian

Billing Information

Is The Billing Address the Same? Yes

Title	First	Last	MI	Suffix

Address:

City:	State:	Zip Code:
Home Phone:
Work Phone:

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 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

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

Referred By:

Referring Doctor:

Primary Vision Correction:
None
Contacts
Single Vision Lenses
Progressive Lenses
Bifocals
Over The Counter Readers

Interested in Contact Lenses?:
Yes
No

Ever Worn Contact Lenses?:
Yes
No

Do you use Sunglasses?:
Yes
No

Interested in Laser Vision Correction?:
Yes
No

Have Backup Glasses for Contacts?:
Yes
No

Please list any hobbies:

Please list any eye conditions, injuries, or surgeries:

Eye Medications:

Artificial Tears Restasis Allergy drops

Last Eye Doctor:

Primary Care Physician:

Systemic Medications:

None
Acne
ADHD
Allergy
Aspirin

Birth Control
Cholesterol
DM
Glipizide
Gout

HTN
Hydrochlorothiazide
Lisinopril
Metformin
NSAIDs PRN

Plaquenil
Synthroid

Other Medications:

Are you Allergic to Medications?:

No Known Drug Allergies

Medical History:
Healthy
Diabetes Mellitus Date Diagnosed: A1c:
Hypertension Date Diagnosed: Well controlled with meds
Hypercholesterolemia
Arthritis
Hepatitis
Hypothyroidism
Hyperthyroidism
AIDS / HIV
Migraines
Gout
ADD / ADHD
Depression / Anxiety

Other:

Immediate Family History:

No medical history known	No eye history known
Diabetes	High Blood Pressure
Glaucoma	Macular Degeneration
Strabismus	Retinitis Pigmentosa
Amblyopia