Online Patient Form

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Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
Occupation Email
Birthday Sex
Marital Status Employment Status
Employer / School NameMisc/Guardian

Billing Information

Is The Billing Address the Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary

Insurance Information
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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision 1

Insurance Information
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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision 2

Insurance Information
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:
Sex:
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!

Eye History

Reason for Visit: Secondary Reasons:

Do you currently have any of the following conditions?

Condition Yes No
Glaucoma
AMD
RD/Ret
Cataract
Lazy Eye/Amblyopia
Vision Loss
Crossed Eyes/Strab
Dryness
Color Blindness
Double Vision
Chronic Eye Infection
Floaters
Flashes


Other


Have you had any eye surgeries? Please describe:

Please describe any eye injuries you have had:


Glasses History Type
No Prior Glasses  
Glasses Lost SV Distance Only
Glasses Broken SV Reading Only
Scratched Lined Bifocals
Did Not Bring Glasses Lined Trifocals
History Progressive Non Adapt Progressive

Contact Lens Wearers only*(If You are not a contact lens wearer, skip to medical history.)*
Type of contacts worn in the past: Interest In Trying Contacts:

Medical History

Medications:
Drug Allergies:

Primary Care Physician:
Referring Physician
Referring Physician Phone#
Other Physicians
Last Medical Doctor Appointment


Do you have any of these medical conditions?:

Condition Yes No
Diabetes
YearDx A1c BS
Hypertension
High Cholesterol
Heart Disease
Thyroid
Cancer
Arthritis
Asthma
Headaches/Mig
Other:

Family Medical History



Does anyone in your family have any of these medical conditions?:

Condition None Mother Father Sibling F Grandmother F Grandfather M Grandmother M Grandfather
Diabetes
Hypertension
Thyroid
Heart Disease
Cancer


Other: Family History Unknown

Family Eye History

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

Condition None Mother Father Sibling F Grandmother F Grandfather M Grandmother M Grandfather
Glaucoma
AMD
Retinal Detach
Cataract
AMB/Strabismus
Blindness


Other


Review of Systems

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

Social History


Smoking Status
Alcohol Use
Illegal Drug

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