Patient Information

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Personal details

First name *

Middle initial

Last name *

Nickname

Birthday

SSN

Birth sex *

Male Female

Pronoun

Marital status

Gender identity

Contact information

Cell phone *

Home phone

Preferred contact method

Mailing address

Street address

Apt / Suite #

City

State

Zip code

Employment & background

Occupation

Employer / school name

Employment status

Employed Full-time student Part-time student

Misc / Guardian

Authorized to release medical info to

Driver's license

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Billing address

Billing address is different from my mailing address

Primary Insurance

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Insurance card

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Plan details

Insurance name

Insurance ID

Insurance policy group

I am not the primary on this account

Secondary Insurance

Upload your medical insurance card and plan details.

Insurance card

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Plan details

Insurance name

Insurance ID

Insurance policy group

I am not the primary on this account

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

Primary vision correction

Do you have backup glasses?

Do you want new glasses?

Contact lens wearers only

Type worn in the past

Cleaner

Disposal

Wear time

Medications & allergies

Medications No medications

Over-the-counter medications

Vitamins

Drug allergies

Please describe any injuries or surgeries you have had

General medical

Primary care physician

Last visit

Reason

Pregnant or nursing

Recent tetanus shot

Recent flu immunization

Do you have any of these medical conditions?

Diabetes

Year diabetes diagnosed

Hypertension

High cholesterol

Thyroid conditions

Heart conditions

Cancer

Other

Family medical history

Does anyone in your family have any of these 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

Smoking type

How long

Alcohol use

Alcohol type

How long

Illegal drug use

Drug type

How long

Race

Ethnicity

Preferred language

STD

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Verification

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Patient Information

Personal details

Contact information

Mailing address

Employment & background

Driver's license

Billing address

Primary Insurance

Insurance card

Plan details

Primary on account

Secondary Insurance

Insurance card

Plan details

Primary on account

Medical History

Eye history

Contact lens wearers only

Medications & allergies

General medical

Do you have any of these medical conditions?

Family medical history

Family eye history

Review of systems

Social history

Review & sign

Verification