Online Patient Forms

Patient information

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

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Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Marital Status

Misc/Guardian

You can you can tell us your SSN in person if you prefer, please enter the last four numbers in the SSN box for now.

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

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?

*This field is required

Have you had any eye surgeries or injuries? Please describe

Last Eye Exam

Last Appointment Type

By Doctor

Ophthalmologist

Last Visit

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Medical History:

Medications No Medications

Over the Counter Medications

Vitamins

Drug allergies

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Do you have any of these medical conditions?

Pre-diabetes or Diabetes

Hypertension

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Year Diabetes Diagnosed

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

Review of Systems (Any NEW problems starting in the last two weeks).

General

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Skin

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Ear/Nose/Throat

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Respiratory

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Musculoskeletal

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Psychiatric

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Endocrine

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Blood/Lymph

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Neurological

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Immune

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Genitourinary

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Gastrointestinal

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Cardiovascular

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Weight (LBS)

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD