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
Mr.
Mrs.
Ms.
Dr.
Rev.
Home Phone:
Work Phone:
Cell Phone:
Other Phone:
Email:
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:
Medications
Allergies
Family Eye Conditions:
Family Medical History:
Tobacco Use:
never
former
current
Other
Alcohol Use:
never
social
frequent
Other
Recreational Drug Use:
never
former
current
marijuana
Other
Hobbies:
Occupation:
Primary Care Provider / Clinic:
Hours outside per day:
Hours on screens per day
Hours driving per day:
Are You Currently Experiencing Any Of The Following?
Dry Eyes
Itchy Eyes
Watery Eyes
Night Driving trouble
Glare
Double vision
Flashes / Floaters
Review of Systems
Eye Health History:
Cardiovascular:
negative
high blood pressure
high cholesterol
heart disease
h/o heart attack
heart stint
arrhythmia
valve prolapse/regurgitation
arterio/atherosclerosis
Other
Lungs:
negative
asthma
COPD
bronchitis
lung cancer
Other
Anemia/Blood:
negative
anemia
cancer
clotting disorder
Other
Digestive:
negative
Crohn's disease
IBS
acid reflux/GERD
cancer
Other
Skin:
negative
rosacea
eczema
dermatitis
skin cancer
Other
Muscles/Bones/Joints:
negative
arthritis
ankylosing spondylitis
cacner
Other
Diabetes/Endocrine:
negative
diabetes type I
diabetes type II
hypothyroid
hyperthyroid
osteoporosis
Hashimoto's thyroiditis
Other
Other:
negative
Other
Mental Health:
negative
depression/anxiety
Attention Deficit Disorder
bipolar
schizophrenia
autism spectrum
Other
Neurological:
negative
migraines
headaches
seizures
Other
Submit Form Patient Signatures
Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.
HIPAA
View HIPAA Patient Privacy Policy Form
Patient Name:
Signature of patient or guardian:
Date:
Payment Policy
View Payment Policy Form
Patient Name:
Signature of patient or guardian:
Date: