Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Cell Phone: Other Phone:
Email Preferred Contact:
SSN Occupation
Birthday Employer/School Name:
Sex Misc/Guardian



Vision Insurance

Primary Vision 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 Vision 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

Eye History

Do you have any of the following eye issues?:

Previous Eye Doctor: Last Eye Exam:

Type of contacts worn in the past: What contact solution do you use?:
How often do you dispose of your lenses?: Do you sleep in your contact lenses?:

Do you or your immediate family currently experience or have a history of any of the following?:

 YouFamilyNo 
Cataract(s)
Lazy Eye
Glaucoma
 YouFamilyNo 
Computer Vision Syndrome
Macular Degeneration
Vitreous Detachment
 YouFamilyNo 
Retinitis Pigmentosa
Blood/Lymph
Color Blindness

Medical History

Do you or your immediate family currently experience problems or conditions in any of the following categories?:

 YouFamilyNo 
Diabetes
Gastrointestinal
Ears/Nose/Throat
Cardiovascular
Respiratory
 YouFamilyNo 
High BP
Nervous System
Genitourinary
Musculoskeletal
Mental
 YouFamilyNo 
Endocrine
Blood/Lymph
Allergic/Immune
Allergies
Medication

Please list any medical or drug allergies you currently have:
Please list all medications you're currently taking:

Vitamins: Over The Counter Meds:
Pregnant Or Nursing:

Preferred Pharmacy:

Visual Demands

Computer Use: Hobbies:

Social History

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

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