Online Patient Forms

Patient Information

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Upload Driver Lisc [back]:

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First Name

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Last Name

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Nickname

Birth Sex

Male Female

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Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Preferred Pharmacy Name/Phone number

Billing Information

Is The Billing Address Different?

Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

Apt/Suite:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Vision Insurance

Insurance Information

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Insurance Name:

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Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Relationship Options:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Medical Insurance

Insurance Information

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Back of the ins card:
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Insurance Name:

*This field is required

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Medical History

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Eye History

Reason for Visit

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Primary Reason

Secondary Reason

Do you currently have any of these symptoms?

Do you currently take any of these medications?

Preferred Pharmacy

Have you had any eye surgeries? Please describe

Last Eye Exam

By Doctor

Primary Vision Correction

Do you:

Have Backup 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

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No Medications

Over the Counter Medications

Vitamins

Drug allergies

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Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Recent COVID Immunization

Do you have any of these medical conditions?

Diabetes

Year Diabetes diagnosed (if applicable)

Hypertension

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Other

Family Medical History

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

Unknown family history

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

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

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

The Wellness Digital Retinal Exam

What is a Digital Retinal exam?
As part of your eye exam, Coan Eye Care recommends a special diagnostic procedure called a Wellness Digital Retinal exam. This procedure gets an image of the back part (retina) of your eye and a 3D cross-section scan through the layers of the retina using light waves without touching your eye.

Why is this exam important?
These scans are a permanent record, which is valuable in assessing the current health of your eye. It will also serve as an initial point to compare, as we follow your health in subsequent years. Our goal is early detection of retinal problems such as retinal holes, retinal detachments, diabetic retinopathy, hypertensive retinopathy, macular degeneration, glaucoma, and eye cancers.

Who should get this exam?
The doctors recommend ALL patients to have a digital retinal scan annually. It is important to note that this is not a substitution for a dilated retinal exam but provides a more extensive look than examination alone.

Yes, I Want The Wellness Digital Exam

No, I Do Not Want The Wellness Digital Exam

Office Policies Agreement

Please review the following agreement. Sign below to acknowledge and attach your signature to the final PDF.

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