Patient Forms

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:		Emergency Contact:
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

Pharmacy Name:*

Address*

Phone*

Billing Information

Is The Billing Address the Same? Yes

Title	First	Last	MI	Suffix

Address:

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

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 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!

Reason for Visit:	Secondary Reasons:

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Please describe any injuries or surgeries you have had:

Primary Care Physician:

Last Visit:

Reason:

Pregnant Or Nursing:

Recent Tetanus Shot:

Recent Flu Immunization:

Do you have any of these medical conditions? Please Choose Yes Or No:

Diabetes:*	Year Diagnosed:
High Blood Pressure:*
High Cholesterol:*
Thyroid Conditions:*
Heart Conditions:*
Cancer:*
Other:

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions? If yes, please describe:

Diabetes:*
High Blood Pressure:*
High Cholesterol:*
Thyroid Conditions:*
Heart Conditions:*
Cancer:*
Other:

Eye History

Have you ever been diagnosed with any eye disease?:*
Do you take any of these eye medications?:*

Have you had any eye surgeries? Please describe: *

Last Eye Exam: *

By Doctor:

Primary Vision Correction:*

Do you: Have back up glasses?*

Want new glasses? *

Want backup sunglasses?:*

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

Are you happy with the comfort of your contacts later in the day?: Yes No

Family Eye History

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

Review of Systems

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

Social History

Hobbies:

STD's:

Smoking Status:*	Type:	How Long:
Alcohol Use:*	Type:	How Long:
Illegal Drug Use:*	Type:	How Long

Race:*

Ethnicity:*

Preferred Language:*

Submit Form

Please read document in link below and sign and date acknowledging you have read it.

View Optos During Covid-19

Signature:*

Date:*

**Click here to view our HIPAA Privacy Policy**

Signature:*

Date:*

By signing the above you acknowledge that you have read and understand our HIPAA policy

** By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I
accept has the same validity and meaning as my handwritten signature.