Patient Information

Tell us a little about yourself. Fields marked with * are required.

Name

First *

Last *

Suffix

Address

Street address

Apt / Suite #

City

State

Zip code

Contact information

Cell phone *

Other phone

Preferred contact method

Birthday

Birth sex *

Male Female

Misc / Guardian

Billing Information

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Billing address is different from my mailing address

Medical History

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Eye History

Reason for Visit

Do you currently have any of these symptoms?

Flashes/Floaters Double Vision Difficulty driving at night Itching Burning/Redness Glare/Light Sensitivity

Have you had any surgeries? Please describe

Last Eye Exam

Primary Vision Correction

Medical History

Medications No Meds Used

Drug Allergies No Known Drug Allergies

Primary Care Physician

Last Visit

Reason

Pregnant Or Nursing

Do you have any of these medical conditions?

Diabetes

High Blood Pressure

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

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

Social History

Hobbies

Smoking Status

Type

Alcohol Use

Type

Illegal Drug Use

Type

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Verification

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