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


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



Primary 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:

Secondary 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!
How (or from who) did you hear about us?
Primary Care Physician:
Last Eye Exam
Medical History: chronic conditions/disease, surgeries, hospitalizations?
Eye History: surgeries, injuries, infections, diseases or other diagnosis?
Family Medical History: hypertension, diabetes, cancers, stroke, or other diagnoses
Hobbies, occupational needs, or other specific visual needs.
Hours per day spent on a digital device?
Eye meds (including OTC):
Eye symptoms: blurry or double vision, dryness, burning, itching, redness, flashes of light, floaters?
Family Eye History: glaucoma, macular degeneration, blindness?
Please list your Use of tobacco products, smoking, alcohol or recreational drugs. if yes, Note amount and frequency.

Review Of Systems

General
Ear, nose and throat
Cardiovascular
Respiratory
Genital, kidney and bladder
Muscles, bones and joints
Skin
Neurological
Psychiatric
Endocrine
Blood/lymph
Allergic/immunologic

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.

Notice of Privacy Practices

View Notice of Privacy Practices

Patient Signature: Date:

* If patient is a minor: I attest that I am the legal guardian with legal authority to make medical decisions for this minor

Guardian Signature: Date: