Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State: Zip:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN: Email:
Birthday: Occupation:
Sex: Male Female Employment Status: Employed
Full-Time Student
Part-Time Student
Marital Status: Employer/School Name:
Primary Doctor: Misc/Guardian:

Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
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:

Secondary


If you do not have any additional insurance, please proceed to the Medical History tab.

Insurance Information
Insurance Name:
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:

Tertiary


If you do not have any additional insurance, please proceed to the Medical History tab.

Insurance Information
Insurance Name:
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 Care Physician :
Ethnicity Race Flu Shot
Referring Doctor:
Primary Vision Correction
Type of CLs worn in past:
Interested In Contact Lenses?
Interested in Laser Vision Correction?
Patient Medical History
Systemic Medication
Allergies:
Family Ocular History:
Tobacco Use:
Alcohol Use:
Height: ft inches
Weight:


Review of Symptoms
Please check box if you have any of the following:

Retinal Detachment
Seasonal Allergies
Sinus Problems
Arthritis
Blindness
Anemia
Asthma
Cancer
Refractive surgey
Bleeding Problems
Chronic Bronchitis

Submit Form

You are almost finished!

Dr. Uyeda's assistant will go over the following files with you in the office. Please read them over so you will be able to determine your options or be ready to ask questions when you come in for your appointment.

1. Medical Records Release
2. Notice of Privacy Practices

When you have completed each tab and read over the files, please click on the submit button.

Thank you!
We will see you at your upcoming appointment.
After completing all tabs, please go to the Submit Form tab and follow the directions.