Online Patient Form

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After completing all the forms, please submit your data on the final tab. Thank you!

Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode

Cell Phone: Home Phone:
Other Phone: Alerts:
Work Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student
Part-Time Student
Marital Status Employer / School Name
Primary Doctor Misc/Guardian

Race: Ethnicity:


Please list all the individuals authorized for us to discuss your health information:
Spouse:
Parent:
Step-Parent:
Other Person:

      May we leave a message on:
      Your answering machine/voicemail at home:
      Your voicemail at work:


Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision 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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Additional 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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History


Please answer none if question does not apply.

Patient Medical Information
Referred By:

Primary Care Physician and exam date:
Medication and Seasonal Allergies:

Medical History Have you experienced any of the following: Headache, Arthritis,Asthma,Diabetes,High Blood Pressure,Heart Disease,Inflammatory Bowel Disease,Seizures,Thyroid,Pregnant,Nursing,HIV+
Current medications, including vitamins:
Do you smoke?
Do you drink alcohol?
Do you use recreational drugs?
Preferred Language:

Family History

Describe family history and which family member has the following history: Ex...(Diabetes-Father)

Family Medical History:
Family Eye History:
Family Patients:


Patient Ocular Information
Eye History
Have you experienced: Sting, Burn, Itch, Surgery,Injury,Cataracts,Lazy Eye, Floaters, Glaucoma, Retinal Problems

Current Eye Medications:

Last Eye Doctor and exam date:

Primary Vision Correction:
Are you interested in contact lenses?
Have you ever worn contacts lenses?
What type of contact lenses have you worn in the past?
Do you have a backup pair of glasses for your contact lenses?
Do you currently wear sunglasses?
Are you interested in Laser Vision Correction?

Any additional information

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