Patient Information and Medical History Form

Thank you for using our secure online forms. Please fill out as much information as you can. When you are finished be sure to hit the submit button at the bottom of the form. If you have any questions, please call us at (607) 257-1066. We can always change the data in the office if you are unsure about what to enter in any of the fields.

Patient Information

*required (first and last name and either a home OR cell phone)

Title	First*	Last*	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr.

Address
City	St NC AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY	Zip

Hm Phone*
Cell Phone*
Wk Phone
Other Phone
SSN
Email
Preferred Contact By	Cell Phone Home Phone Work Phone Other Phone Text Message Email
DOB (mm/dd/yyyy)
Sex	Female Male
Marital Status	Single Married Separated Divorced Widowed Unknown
Employment Status	Employed FT Student PT Student
Occupation/Grade
Employer/School
Parent/Guardian

Who may we thank for referring you to our office?  

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr.

Address
City	St NC AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY	Zip
Hm Phone
Wk Phone

Medical History

Do you have difficulties with any of the following systems?  Nervous System    Mental    Respiratory  Headaches    Cardiovascular    Skin  Ear/Nose/Throat    Musculoskeletal    Allergic/Immunologic  Genitourinary    Endocrine(Glands)    Blood/Lymph Please list the date and type of surgeries you have had: Are you in good general health? Yes   No  Do you have any allergies to medications or other substances? Yes  No   If yes, please list Name and phone number of Primary Care Physician?  Do you smoke? Yes   No  How much?     Per  Do you use any other substances? Yes   No  If yes, please list:  Current medications: (Please list names and how often) Do you or any of your relatives have a history of any of the following?  High Blood Pressure Relation:     Retinal Detachment Relation:   Macular Degeneration Relation:    Glaucoma Relation:   Diabetes Relation:                              Cataracts Relation:  What is the reason for your visit today? Are you interested in LASIK vision correction?  Yes  No I certify that the information I have provided is complete and accurate to the best of my knowledge. Signature:   Date:    Relation:  You're Done! Please hit the Submit button below.