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


Provide ONLY One Phone Number Per Entry

TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address the Different?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID (No Dashes):
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 Information
Insurance Name:
Insurance Plan:
Insurance ID(No Dashes):
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!

Eye History

Reason for Visit:
Primary Reasons: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: Last Appointment Type By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Medical History

Medications: Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot: Recent Flu Immunization:


Do you have any of these medical conditions?:

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History



Does anyone in your family have any of these medical conditions?:

High Blood Pressure: Diabetes:
Thyroid Conditions: High Cholesterol:
Heart Conditions: Other:
Cancer:

Family Eye History

Does anyone in your family have any of these eye conditions?:

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Blindness:

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:

Social History

Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:
STD

COVID-19 SCREENING

In Order To Assure The Utmost Safety Of Our Patients And Staff, Please Answer The Following Questions

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

  Yes No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled?
Have you had a fever in the last 48 hours or temperature greater than 99.5 degrees?
Have you or a member of your household had close contact with or cared
for someone with a presumptive positive case of COVID-19 in the last 14 days?
If you had COVID-19 and recovered, have you had at least 2 negative test
and self-isolated for at least 14 days afterwords? N/A


iWellness Exam And Optos Form



Did you know sight threatening diseases such as diabetic retinopathy, macular degeneration, glaucoma as well as many others often have no outward signs or symptoms? Eye exams including a thorough retinal evaluation, are important to protect your vision. Dr. Jerry Latham and Associates highly recommend having the state-of-the-art digital technology, iWellness and Optomap, performed every year as part of your annual eye examination.

Please click on the blue link below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

View iWellness Exam And Optos Flyer

I elect to have the iWellness screening to evaluate my optic nerves today ($45.00)
I elect to have the Otomap to evaluate my retinas today ($45.00)
I elect to have BOTH the iWellness and Optomap to evaluate my optic nerve and retina today ($75.00)
I will decline all options today and I understand that the doctor highly recommends them to evaluate my ocular health

Submit Form / Signatures


Signature: Date:

** By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I
        accept has the same validity and meaning as my handwritten signature.