Online Patient Forms

Demographics

Title	First	Last	MI	Suffix	Nickname

Address:		Apt/Suite #:
City:		State:	ZipCode:

Email:	Cell Phone:
Work Phone:	Preferred Contact Method:

SSN:	Sex:	Male Female
Birthday:	Occupation:

Billing Information Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address	Apt/Suite #

City	State	ZipCode

Home Phone:
Work Phone:

Vision Insurance

Insurance Information

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance

Insurance Information

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Primary Reason For Visit Today

Looking For Frames Or Purchasing Glasses Today? Yes No

Last Eye Doctor:

Primary Care Physician:

Preferred Pharmacy

Medications (including OTC): - No current medications

Allergies: - No Known Drug Allergies

Preferred Language

Smoking Status

Do Your Eyes Sting, Burn, Itch, Or Feel Dry?
Have You Had An Eye Injury Or Been Diagnosed With Cataracts, Lazy Eye, Retinal Problems, Or Glaucoma?

Do You Have a History Of Headaches? Arthritis? Asthma? Diabetes? High Blood Pressure?
Heart Problems? Inflammatory Bowel Disease? Seizures? Thyroid Problems?
Do You Smoke? Are You Pregnant? Are You Nursing? Are You HIV+?
If Yes, Please List Below.

Does Anyone In Your Family Have/Had Diabetes? Lupus? Cancer? High Blood Pressure? Heart Problems? Auto-Immune Disease?
If Yes, Please List Below.

Does Anyone In Your Family Have/Had Glaucoma? Macular Degeneration? Retinal Detachment? Other Retinal Disorders?
If Yes, Please List Below.

Any Other Relevant Information?

Reading Symptoms

I wear glasses
Full time Part time Sometimes
Far only Near only Both

If yes, age when first worn:

I wear contact lenses
Full time Part time Sometimes

If yes, age when first worn:

I work on a computer
Glasses worn: Yes No

If yes, hours per day:

COVID-19 SCREENING

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition	Yes	No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact
With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared
For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact
With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis,
Or Have You Been Asked To Quarantine?

Submit Data / Patient Signatures

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Notice of Privacy Practices

View Notice of Privacy Practices Form

Patient Signature: Date: