Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

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Home Phone

Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Billing information

Is The Billing Address Different? Yes

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Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

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Medical History

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Eye History

Reason for Visit

Primary Reason

Secondary Reason

Do you currently have any of these symptoms?

Do you currently take any of these medications?

Have you had any eye surgeries? Please describe

Last Eye Exam

Last Appointment Type

By Doctor

Ophthalmologist

Last Visit

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Medical History:

Medications No Medications

Over the Counter Medications

Vitamins

Drug allergies

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Recent Tetanus Shot

Recent Flu Immunization

Do you have any of these medical conditions?

Diabetes

Hypertension

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Year Diabetes Diagnosed

Other

Family Medical History

Unknown family history

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

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?

Unknown family eye history

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Social History

Hobbies

Patient Signatures

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-Notice of Privacy Policy View Notice of Privacy Form

Signature

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Date

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-Insurance Policies and Billing Procedures View Insurance Policies and Billing Procedures Form

Signature

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Date

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