Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

*This field is required

Apt/Suite #

City

*This field is required

State

*This field is required

Zip Code

*This field is required

Cell Phone

*This field is required

Home Phone

*This field is required

Preferred Contact Method

Birthday

*This field is required

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

Title

First

Last

Middle

Suffix

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Please choose from the menu options or select the option to type in your own text. Thank you!

Tech:

Medical Complaint

Optical OR Secondary Complaint

Notes:

Location

Duration

Severity

Timing

Modifying Factors

Quality

Context

Associated Symptoms

Surgical Procedure OD:

Surgery Date

*This field is required

Surgical Procedure OS

*This field is required

Surgery Date

*This field is required

Surgeon OD

Patient Ocular History

Ocular Surgical History

Ocular Meds

Pregnant Or Nursing

Family Medical History

Family Ocular History

Tobacco

Alcohol

Rec Drugs

Hobbies

BF/TF

PAL

Readers

Last Eye Exam

Computer Use: hrs/day

Cell Phone Use: hrs/day

Type

Past CL Rx OD

Past CL Rx OS

NKDA

Wear Time

No Current Meds

Replacement

Cleaner

Notes:

Reviewed By Doctor

GENERAL: Fever, weight loss, weight gain, fatigue

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat, hearing loss

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

GENITAL, KIDNEY, BLADDER: Kidney Stones, Freq Urination, impotence

MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury

SKIN: growths, rashes, acne

NEUROLOGICAL: Headaches, migraines, seizures

PSYCHIATRIC: Depression, Anxiety, Insomnia

ENDORCRINE: Thyroid, Diabetes

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems

ALLERGIC/IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, Lupus

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

Reviewed By Doctor

Patient information

Billing information

Primary Vision Insurance

Primary Medical Insurance

Please choose from the menu options or select the option to type in your own text. Thank you!

monday	09:00am - 06:00pm
tuesday	09:00am - 06:00pm
wednesday	09:00am - 04:00pm
thursday	09:00am - 06:00pm
friday	09:00am - 05:00pm
saturday	Call For Availibilty
sunday	Closed