Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex
Marital Status Employer / School Name
Misc/GuardianDrivers License #



Primary Vision Plan

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

Primary Medical Insurance

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

Secondary Medical Insurance

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

Secondary Vision Plan

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

Other

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:
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!

Primary Care Physician
Last Medical Dr Appt
Last Eye Exam
Last Eye Dr
Pharmacy

Smoking Status
Alcohol Use
Illegal Drug

Race
Preferred Language
Ethnicity


Patient Ocular History

Patient Ocular Conditions (e.g. dry eyes, cataracts, floaters, glaucoma, macular degeneration etc.)
Ocular History (e.g. eye injuries, eye surgeries, retinal detachment etc.)
Eye Medications (e.g. prescription or over the counter eye drops)

Patient Medical History

Endocrine:
If Diabetic: YrDx A1c
Allergic/Immunologic:
Musculoskeletal:
Cardiovascular:
Constitutional(Current):
Ears, Nose, Throat:
Gastrointestinal:
Genitourinary:
Integumentary (Skin):
Lymphatic/Hematologic:
Neurological:
Psychiatric:
Respiratory:
Cancer:
Other:
Other Patient Medical Conditions

Medications - No current medications
Allergies - No known drug allergies


Family Ocular History

Glaucoma
Macular Degeneration
Retinal Detachment
Cataract
Amblyopia / Strabismus
Blindness
Other Family Ocular Conditions

Family Medical History

Diabetes
Hypertension
Thyroid
Heart Disease
Cancer
Other Family Medical Conditions - Family History Unknown

Submit Data / Patient Signature



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Notice of Privacy Practices

View Notice of Privacy Practices Form

Patient Signature: Date: