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
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
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
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer / School Name
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Yes
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
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
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Insurance Information
Vision 1
Insurance Information
Insurance Name:
None
Advantica Eye Services
Always Vision
Avesis
BCBS
Cigna Medical
Cigna Vision
Davis Vision
Heritage Vision
MES Vision
National Vision Administrators
Spectera
Superior Vision Plan
SVS Vision Managed Care Inc
United Healthcare
Vision Benefits of America
VSP
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:
None
Advantica Eye Services
Always Vision
Avesis
BCBS
Cigna Medical
Cigna Vision
Davis Vision
Heritage Vision
MES Vision
National Vision Administrators
Spectera
Superior Vision Plan
SVS Vision Managed Care Inc
United Healthcare
Vision Benefits of America
VSP
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:
None
Advantica Eye Services
Always Vision
Avesis
BCBS
Cigna Medical
Cigna Vision
Davis Vision
Heritage Vision
MES Vision
National Vision Administrators
Spectera
Superior Vision Plan
SVS Vision Managed Care Inc
United Healthcare
Vision Benefits of America
VSP
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?:
no complaint
blurry vision
broken glasses
burning
discharge
double vision
dryness
failed DMV
failed vision screening
flashes
floaters
headaches
injury to eye
itching
laser vision consultation
light sensitivity
loss of vision
lost glasses
pain
redness
referred by MD
routine exam
stinging
strain
tearing
want new eyeglasses
wants contact lenses
Other
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:
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