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

*This field is required

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:

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Medical History

Primary Care Physician

Primary Vision Correction

Age of Glasses

If not, are you interested in contacts?

Type of CLs worn in past:

Medications

No current medications

Allergies

No known drug allergies

Vitamins

OTC

Injuries, Surgeries, Hospitalization

Pregnant Or Nursing

Diabetes

Year Diagnosed

HbA1c

Do you have any of the following?

Hypertension

High Cholesterol

Thyroid

Cardiovascular

Cancer

Other

Review of Ocular System

Ocular History

Ocular Surgery

Eye Meds/Drops

Droopy lids

Dry eyes

Family Eye History

Glaucoma

Cataracts

Macular Degeneration

Retinal Detachment

Crossed / Lazy Eye

Blindness

Notes

Family Medical History

Unknown Family History

Diabetes

Hypertension

High Cholesterol

Thyroid

Cardiovascular

Cancer

Other

Social History

Do you drive?

If yes, do you have difficulty when driving?

If yes, describe:

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

STD

Race

Ethnicity

Preferred Language

Review of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Notes