Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

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

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Medical History

Please choose from the menu options/ type your own text

Emergency Contact Person:

Emergency Phone #:

Referred By:

Referring Doctor:

List Any Family Members Who Are Patients:

Hobbies:

Occupation

Interested In Contact Lenses?

Ever worn Contact Lenses?

Type of Contacts Worn: Disposable Soft, Dailies, Torics, Multtifocals, RGPs,etc

Do You Wear Glasses When Not Wearing Contacts?

Do You Wear Sunglasses?

Primary Vision Correction

Interested in Laser Vision Correction?

PATIENT EYE HISTORY: Please list all Injuries,Infections,Surgeries and Diseases of your eyes and dates of occurrence.

List All Current Eye Medications:

Name of Last Eye Doctor and Phone #:

Name of Last Primary Care Physician:

Phone Number:

Endocrinologist:

Phone Number:

List All Other Current Medications (Non-Eye):

PATIENT MEDICAL HISTORY: Diabetes,High Blood Pressure,Cancer,Heart Disease or Other Conditions.

FAMILY MEDICAL HISTORY: Diabetes,High Blood Pressure,Cancer,Heart Disease or Other Conditions.

FAMILY EYE HISTORY: Glaucoma,Macular Degeneration,Retinal Detach,Cataract or Other Conditions.

List All Medications That You Are Allergic To:

SOCIAL HISTORY: Please answer the question concerning alcohol,tobacco or illegal drug use

Signature Forms

Please click the blue links, read carefully and check the designated box

View Patient Responsibility Disclosure Statement
I have read and understand the Patient Responsibility Disclosure Statement for Austin Eye Care.

*This field is required

View HIPAA Privacy Policies
I have read and understand the HIPAA Privacy Policies for Austin Eye Care.

*This field is required