Online Patient Form

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Patient Information


Title Legal First Name MI Legal Last Name
Suffix Nickname
Address:
City: State: Zip Code:
Cell Phone: Home Phone:
Work Phone: Other Phone:
Email SSN
Date of Birth Sex

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

Main Reason for Eye Exam:
Secondary Reasons:

Do you have any of these eye conditions?: Other
Have you had any eye surgeries?: Other
Have you had any Ocular Treatments?: Other
Do you take any eye medications? (Incl. OTC Drops):
Ocular Review of Systems:

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, surgeries or hospitalizations you have had:

Pregnant Or Nursing:


Do you have any of these medical conditions?:

Conditions: Other
Diabetes: Year Diagnosed: Blood Sugar A1c

Family Medical History



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

Conditions: Other

Family Eye History

Does anyone in your family have any eye conditions?:

Conditions: Other

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:

Social History


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


STD

Race: Preferred Language:

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