Online Patient Form
After completing all the forms, please submit your data using the button on the final page. Thank you!
Demographics
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fields are required.
Title
Select
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
First
Last
MI
Address:
Suite/Apt #:
City:
State
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NY
AL
AK
AZ
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CA
CO
CT
DE
DC
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ID
IL
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ME
MD
MA
MI
MN
MS
MO
MT
NE
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NH
NJ
NM
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
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UT
VT
VI
VA
WA
WV
WI
WY
ZipCode:
Home Phone:
Preferred Contact:
Select
Home Phone
Cell Phone
Text Message
Email
Cell Phone:
Email
Birthday
Sex
Male
Female
F
Please click the buttons below to submit additional information.
Medical
Insurance Name:
Select
None
Medicare
Private Payment
United HealthCare Choice Plus
United Healthcare Community Plan NY
United Healthcare Medicare Advance PPO
United Healthcare Oxford
United HealthCare Select Plus
UnitedHealthcare PPO
Insurance ID:
Not Primary on Account:
Not Primary
Primary on Account
Last
First
MI
Name:
Relationship to Insured:
Spouse
Child
Other
Sex:
Male
Female
Address:
City:
State:
Zip:
Phone Number:
Birthday:
Employer/School:
Medical History
Date of last eye exam:
Doctor's name:
Allergies:
List significant or chronic illnesses (Headaches, Arthritis, Asthma, Diabetes, High Blood Pressure, Heart Problems, IBS, Seizures, Thyroid Problems):
Primary Reason For Visit Today:
Medications (Including vitamins and supplements):
Policies, Consent and Submit Data
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Patient Signature:
Date: