Online Patient Form

Click here to return to the previous website.

After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information


Title Legal First Name MI Legal Last Name
Suffix Nickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: SSN
Birthday Email
Sex Occupation
Marital Status Employment Status
Misc/Guardian Employer / School Name

Billing Information

Is The Billing Address the Same?
Title
First MI Last
Suffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Vision Insurance Primary

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:

Vision Insurance Secondary

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:

Other Insurance

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

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Eye History

Exam Type
Main Reason for Eye Exam:
Secondary Reasons:

Do you have any of these eye conditions?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: Last Appointment Type By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:
Anything you wish was different about your glasses or eyewear?

Contact Lens Wearers only
Contact Lens Type: Contact Lens Brand: Disposal:
Any Dryness at the end of the day?:
Anything you wish was different about your contacts?:

Medical History

Medications:
Over The Counter Medications:
Vitamins:
Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing:


Do you have any of these medical conditions?:

Diabetes: Year Diagnosed: Blood Sugar A1c
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History



Does anyone in your family have any of these medical conditions?:

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

Family Eye History

Does anyone in your family have any of these eye conditions?:

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:

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

Discussed Cessation Tobacco Use Tobacco Use Screening

Tobacco Non User Tobacco Use Ceasation Counseling Reason Tobacco Use Screening Not Done

STD

Race: Ethnicity: Preferred Language:

Submit Form