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!

I understand that in accordance with the FCLCA and FTC regulations, my prescription, once finalized, will be made available in electronic format for me to access at my convenience in the patient portal and that this constitutes my acknowledgement of receipt of my prescription. I understand and agree to all statements made herein and understand that my signature will be collected digitally after all forms have been accepted.

Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
Occupation Email
Birthday Sex
Marital Status Employment Status
Employer / School NameMisc/Guardian

Billing Information

Is The Billing Address the Same?
TitleFirstLastMISuffix
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!

Eye History

Reason for Visit: Secondary Reasons:

Do you currently have any of the following conditions?

Condition Yes No
Glaucoma
AMD
RD/Ret
Cataract
Lazy Eye/Amblyopia
Vision Loss
Crossed Eyes/Strab
Dryness
Color Blindness
Double Vision
Chronic Eye Infection
Floaters
Flashes
Keratoconus


Other


Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:

Please describe any eye injuries you have had:

Last Eye Exam: Location By Doctor:

Want new glasses?

Contact Lens Wearers only*(If You are not a contact lens wearer, skip to medical history.)*
Type of contacts worn in the past: Cleaner: Replacement schedule:
Hours per day you wear contacts:

Medical History

Medications:
Drug Allergies:

Primary Care Physician: Referring Physician Referring Physician Phone#


Do you have any of these medical conditions?:

Condition Yes No
Diabetes
YearDx A1c BS
Hypertension
High Cholesterol
Heart Disease
Thyroid
Cancer
Arthritis
Asthma
Headaches/Mig
Other:

Family Medical History



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

Condition None Mother Father Sibling F Grandmother F Grandfather M Grandmother M Grandfather
Diabetes
Hypertension
Thyroid
Heart Disease
Cancer


Other: Family History Unknown

Family Eye History

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

Condition None Mother Father Sibling F Grandmother F Grandfather M Grandmother M Grandfather
Glaucoma
AMD
Retinal Detach
Cataract
AMB/Strabismus
Blindness
Keratoconus


Other


Review of Systems

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

Social History


Smoking Status:

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