Online Patient Forms

Patient Information

First Name

*This field is required

Last Name

*This field is required

Nickname

Birth Sex

Male Female

*This field is required

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

How did you hear about us?

Doctor Preference

Billing Information

Is The Billing Address Different?

Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

Apt/Suite:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Medical Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Relationship Options:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Vision Plan/Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Chief Complaint

Please choose from the menu options or select the option to type in your own text. Thank you!

Reason for Visit

Secondary Reason

Review of Ocular System

Ocular History

Eye Meds

Last Eye Exam

Doctor

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Type of CLs worn in the past

Cleaner

Disposal

Wear Time

Days per Week

Hours Worn Comfortably

Family Eye History

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

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Medical History

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Vitamins

Over the Counter Medications

Medications

No Medications

Drug Allergies

No Known Drug Allergies

Please Describe any Injuries or Surgeries you have had

Family Medical History

Please choose from the drop down medical issues that have occured within your family. If there are multiple, please use the extra boxes provided. Thank you!

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Occupation

Hobbies

Tobacco Use

Alcohol Use

Illegal Drug Use

Office Policies Agreement

Please review the following agreement. Sign below to acknowledge and attach your signature to the final PDF.

Please ADD the above numbers together.