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


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 Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary Insurance

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Insurance

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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary Insurance

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:
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 Problems

 YesNoWhat is the particular problem?Does anyone in your family have this? If yes, who?
Glaucoma  
Cataracts  
Macular Degeneration  
Retinal Detachment  
Eye Turn  
Lazy/Crossed Eye  

List any eye surgeries: (List what kind and when)
Describe any eye injuries:

Medical problems

Date of Physical Exam: Physician's Name:

 YesNoWhat is the particular problem?Does anyone in your family have this? If yes, who?
Cancer  
Diabetes  
High Blood Pressure  
Stroke  
Thyroid Disease  
Asthma  
Emphysema  
Heart Disease  
Kidney Disease  


Any problems with the following systems of your body?

 YesNoWhat is the particular problem?
Head/Neck:  
Ear/Nose/Throat:  
Respiratory:  
Gastrointestinal:  
Skin:  
Muscles:  
Bones/Joints:  
Blood/Lymph:  
Psychiatric:  
Neurological Problems:  
STD's:  

List MAJOR illnesses and injuries: (What kind and when)
List any [non-optical] surgeries:


Do you use tobacco products?:   If yes, type/amount/how often:
      Smoking Status:
Do you drink alcohol?:   If yes, type/amount/how often:
Do you use illegal drugs?:   If yes, type/amount/how often:


Preferred Language: Race: Ethnicity:

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