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


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Other Phone: Notes:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex
Employer / School Name
Misc/Guardian

Personal History

How Did You Hear About Us? If Referred By A Friend Or Family Member, Whom May We Thank For The Referral
Date of Last Eye Exam Name of Previous Eye Doctor
Currently Wear Glasses? Currently Wear Contact Lenses ?
Computer Use (Hours/day)? Interested In Contact Lenses?
Hobbies / Special Visual Needs: Interested In New Glasses Today?
Favorite Music Genre / Artist? Interested In Sports Vision Training?
Are You Interested In LASIK? Do You Have Prescription Sunglasses?
Do You Have Any Problems With Current Contacts Or Glasses?

Please List Any Visual Needs You Currently Have:?

Reason's For Visit (Please Select All That Apply)

VISION Complaint
MEDICAL Complaint

Ocular History: Review Of Systems

Have YOU or anyon in your IMMEDIATE FAMILY ever been diagnosed with an Ocular Condition?

Myself Family Condition
Glaucoma
Macular Degeneration
Cataracts
Retinal Detachment
Lazy Eye
None
Other Please Explain


Personal Ocular History - additional


Medical History



Have YOU or anyone in your IMMEDIATE FAMILY ever been diagnosed with a Medical Condition?

Myself Family Condition
High Blood Pressure
Diabetes
Arthritis
Cancer
Multiple Sclerosis
Thyroid Disease
None
Other Please Explain


Drug Allergy
Current Meds

Name of Primary Care Physician
NOTES/Personal History

Social History

Drink Alcohol?
Use Illegal Drugs?
Use Tobacco?
Smoking Status

Vision Insurance

Insurance Information
Insurance Name:
Insurance Plan:
Member ID:
Insurance Policy Group:

If You Are Not The Primary On The Insurance Please Fill Out The Section Below Regarding The Primary:

Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance

Insurance Information
Insurance Name:
Insurance Plan:
Member ID:
Insurance Policy Group:

If You Are Not The Primary On The Insurance Please Fill Out The Section Below Regarding The Primary:

Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:


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

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Please remember to bring the following items with you to your exam:

  • Vision and Medical Insurance Cards
  • Copy of previous prescriptions (if available)
  • Current Glasses - distance, reading, sunglasses, and computer glasses
  • Current Contact Lens Prescription (a photo of the numbers on the boxes will work)
  • List of current medications
  • Any drops you are currently using