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


TitleFirstLastMISuffixNickname
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:
Alcohol Use:
Recreational Drug Use:


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: Lungs:
Anemia/Blood: Digestive:
Skin: Muscles/Bones/Joints:
Diabetes/Endocrine: Other:
Mental Health: Neurological:

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: