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

Address:

City:		State:		Zip Code:

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address the Same? Yes

Title	First	Last	MI	Suffix

Address:

City:		State:		Zip Code:
Home Phone:
Work Phone:

Insurance Information

Vision 1

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:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision 2

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:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical

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:	Spouse Child Other
Sex:	Male Female
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!

What is your main reason for visit?:

Do you wear glasses?:	Yes	No
If yes, do you wear them for:	Distance	Near	Both
Do you wear Contacts?:	Yes	No

Date of Last Eye Exam:
Date of Last Medical Exam:
Primary Care Physician:

Do you have any allergies to medication?:

Yes

No

If yes, please list:

Do you have seasonal allergies?:	Yes	No
Are you taking medications?:	Yes	No

List Medications:

List Eye Medications:

Do you have:

None
High Blood Pressure
Diabetes
High Cholesterol
Thyroid Disease
Rheumatoid Arthritis
Asthma
Heart Disease
Multiple Sclerosis
Cancer
Other

Have you ever had eye surgery for:

None

Cataract Surgery

Lasik/PRK

Retinal Detachment

Strabismus Surgery

Have you ever had:

None
Strabismus (eye turn)
Cataracts
Eye injury
Amblyopia (lazy eye)
Glaucoma
Diabetic Retinopathy
Macular Degeneration
Dry Eyes
Retinal Disease
Other

Does anyone in your family have:

Condition	Mother	Father	Grandmother	Grandfather	Siblings
Cancer
Diabetes
Cholesterol
Heart Disease
Hypertension
Thyroid
Blindness
Glaucoma
AMD
Amblyopia
Strabismus
Strabismus

Other

Are you pregnant?:	Yes	No
Do you see flashes of light in your eyes?:	Yes	No
Do you see floating objects in your eyes?:	Yes	No
Do you have frequent headaches?:	Yes	No
Do you smoke?:	Yes	No
Do you drink alcohol?:	Yes	No
Are you nursing?:	Yes	No
Do you have temporary blackouts of your vision?:	Yes	No
Former smoker?:	Yes	No

Occupation:

Number of hours spent on computer:

Visual Fields Screening: This helps discover diseases not readily visible such as brain tumors, damage to deep nerve fibers, and early stages of glaucoma. Our charge for this procedure is $5.

Retinal Photography: A medical camera that takes a high resolution picture inside the eye. Usually this takes the place of the $20 dilation. This procedure is quicker, easier, more efficient and much more comfortable than all other types of retinal viewing. Normally, this is an $80 procedure. Our charge is only $10.

I understand that I will pay $15 for these two procedures

I want these tests done

Yes

No

If no: I accept the risk for refusing these tests. Initial:

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