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

City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name

Emergency Contact Name
Phone Number

New Patient's Only: How Did You Hear About Our Office?
Please Specify Name of person whom referred you

Billing Information

Is The Billing Address Different? If Yes Fill Out Below:
City: State: Zip Code:
Home Phone:
Work Phone:

Vision Insurance

Insurance Information
Insurance Name:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
City: State: Zip:
Phone Number:

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 Reasons: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye Infection, Disease, Injury, or Surgery? Please describe:
Last Eye Exam: Last Appointment Type By Doctor:

Primary Vision Correction:

Age of current glasses? Do you:    Have back up glasses? Want new glasses?
Interested in Contact Lens? Have You Ever Worn Contact Lens? Want New Sunglasses?:

Interested In Learning About LASIK?: Hours spent on a computer or digital device daily:
Interested in computer glasses with Blue Light protection?: Want to learn about Ortho-K therapy for myopia control or freedom from glasses?

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:
Brand BC Diam SPH CYL Axis Add

Medical History

Medications: Over The Counter Medications:
Vitamins: Drug Allergies or Adverse Reaction To Eye Drops:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Covid Vaccine: Recent Flu Immunization:

Do you have any of these medical conditions?:

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

Family Medical History

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

High Blood Pressure: Diabetes:
Thyroid Conditions: High Cholesterol:
Heart Conditions: Other:

Family Eye History

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

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

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:

Social History


Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:

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