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

Title	First	Last	MI	Suffix	Nickname

Address:

City:		State:		Zip Code:

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer / School Name
Misc/Guardian
Pharmacy:
Pharmacy Address:
Pharmacy Phone number:

Billing Information

Is The Billing Address the Same? Yes

Title	First	Last	MI	Suffix

Address:

City:		State:		Zip Code:
Home Phone:
Work Phone:

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:	Spouse Child Other
Sex:	Male Female
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!

Reason for Visit:	Secondary Reasons:

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Please describe any injuries or surgeries you have had:

Primary Care Physician:

Last Visit:

Reason:

Pregnant Or Nursing:

Recent Tetanus Shot:

Recent Flu Immunization:

Do you have any of these medical conditions? If yes, please describe:

Diabetes:		Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions? If yes, please describe:

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:

Have you had any eye surgeries? Please describe:

Last Eye Exam:

By Doctor:

Primary Vision Correction:

Do you: Have back up glasses?

Want new glasses?

Want backup sunglasses?:

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

Family Eye History

Macular Degen:		Glaucoma:
Retinal Detach:		Cataracts:
Lazy/Crossed Eye:		Blindness:

Review of Systems

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

Social History

Hobbies:

STD's:

Smoking Status:		Type:		How Long:
Alcohol Use:		Type:		How Long:
Illegal Drug Use:		Type:		How Long

Race:

Ethnicity:

Preferred Language:

COVID-19 SCREENING

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition	Yes	No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis, Or Have You Been Asked To Quarantine?

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