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


Title First Last MI Suffix Nickname Pronoun
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Birth Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian



Primary Routine 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:

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 / Chief Complaint


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:


Needs New Glasses? Sports Glasses? Prescription Sunglasses?

Contact Lens Wearers Only

Type of contacts worn in the past:


Medications: - No Meds Used Over The Counter Medications:
Vitamins: Drug Allergies: - No Known Drug Allergies
Please describe any injuries or surgeries you have had:


Primary Care Physician: Last Visit: Reason:

Do you have any of these medical conditions?

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

Family Eye History

Does anyone in your family have any of these eye conditions? Please list all family members below.


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

Social History


Hobbies:
Smoking Status:
Alcohol Use:
Preferred Language:

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