Online Patient Information Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
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Please Select
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E-mail
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Birth Date
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Year
Gender
*
Male
Female
N/A
Home Phone
*
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Is this your first visit to our office?
*
Yes
No
Please tell us the reason(s) for your upcoming visit (check all that apply):
Exam
Eye infection
Glasses
Injury
Contacts
Lasik Consult
Are you planning on getting glasses this visit?
Yes
No
If Necessary
Insurance Information
If you have Medicare, Blue Cross Blue Shield or United Healthcare, please provide the information found on your insurance card.
Last 4 digits of Primary Insured Social Security #:
*
(we will need this to pull insurance information)
Policy Holder's First Name:
*
Policy Holder's Last Name:
*
Policy Holder's Date of Birth:
*
(MM/DD/YYYY Format)
Vision Insurance
*
Please Select
None
Aetna
BCBS Vision
Cigna
Davis
EyeMed
MetLife
United Healthcare
VSP
Not Listed
Medical insurance
*
Please Select
None
Aetna
Blue Cross Blue Shield
Cigna
Humana
Medicare
United Healthcare
Not Listed
Member ID #:
Medical Group #:
Medical History
To help our office better serve your specific needs, please check all that apply. Please leave boxes unchecked for a "NO" answer.
Eye History (please only check for present issues. Select "None" if no issues exist):
*
Headaches
Eye Infection
Drooping Eyelid
Crossed Eyes
Floaters or Spots
Loss of Side Vision
Macular Degeneration
Color Blindness
Amblyopia (lazy eye)
Double Vision
Cataract(s)
Light Sensitivity
Excess Watering
Sandy or Gritty Feeling
Blurred Vision Distance
Distorted Vision (halos)
Foreign Body Sensation
Retinal Detachment
Blindness
Eye Pain or Soreness
Blurred Vision Near
Tired Eyes
Redness
Itching
Dryness
Burning
Loss of Vision
Glaucoma
Diabetic Retinopathy
Fluctuating Vision
Mucous Discharge
None
General Health Condition
Please provide your family doctor's name, address, and contact information:
*
(If you do not have a primary healthcare physician state "None")
List all major injuries, surgeries, and/or hospitalizations you have had:
Current Health Conditions (please select "None" if there are no current issues):
*
Kidney
Ears, Nose, Throat
Neurological
Joint Pain
Bleeding Problems
Diabetes
Pregnant or Nursing
Smoke Cigarettes
Consume Alcohol
High Blood Pressure
Dry Mouth/Throat
Rheumatoid Arthritis
Gastrointestinal
Fever
Allergic
Skin
Endocrine
Anemia
Genitals/Bladder
Sinus Congestion
Post Nasal Drip
Lupus
Elevated Cholesterol
Chronic Bronchitis
AIDS/HIV
Weight Loss
Muscles, Bones, Joints
Respiratory
Psychiatric
Cardiovascular Disease
Heart Disease
Cancer
Runny Nose
Chronic Cough
Stroke
Thyroid Disease
Emphysema
Blood/Lymph
None
Family History (if there are no issues, please select "None"):
*
Stroke
Amblyopia (lazy eye)
Arthritis
Cancer
Macular Degeneration
Retinal Detachment
Glaucoma
High B.P.
Color Blindness
Thyroid Disease
Lupus
Diabetes
Kidney Disease
Crossed Eyes
Cataract(s)
Blindness
Heart Disease
None
Other
Please list all current medication(s) with the condition you take them for - prescription and over the counter:
*
(If you do not currently take any medication(s) please state "None")
Do you have any allergies to medications?
*
Yes
No
If yes, please list medication(s):
Do you have allergies to anything that is not a medication?
*
Yes
No
If yes, please list:
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