Submit as Guest Print Form Patient Form Complete and submit this form before your appointment. Basic Information To 'Submit' form, all required fields in this section must be filled out. First Name * MI Last Name * Sex * Male Female Date of Birth * Age 0 Marital Status * SSN Last 4 * Street Address/PO Box * City * State * Zip * Employment Status Occupation Allow Messaging Home Text Email To 'Submit' form, please enter at least one method of contact. Home Phone Cell Phone Email Address Employer Info Employer Name Phone Street Address/PO Box City State Zip Other Contact Info Person responsible for charges Relationship to Patient Phone Emergency contact Emergency contact relationship Phone Visit Information Last eye exam date First Visit Yes No Reason for current visit Referred by Eye Health Check all that apply Amblyopia Blurred Vision - Far Blurred Vision - Near Burning Eyes Cataracts Double/Distorted Vision Drooping Eyelid Dry Eyes Eye Surgeries Eye Turn Floaters/Spots Fluctuating Vision Foreign Body Sensation Glaucoma Glare/Light Sensitivity Headaches Itchy Feeling Infection of eye/lid Loss of Vision - Central Loss of Vision - Side Mucus/Discharge Redness Retinal Detachment Tearing/Watery Eyes General Health Check all that apply Allergies/Hay Fever Asthma/Respiratory Blood Disorders Cancer Cardiovascular/High BP Chronic Bronchitis Chronic Cough Diabetes Emphysema Gastrointestinal Problems Heart Attack/Strokes Headaches/Migraines Kidney Disease Psychiatric Depression Rheumatoid Arthritis Thyroid/Endocrine Disease Skin Disorders Weight Loss/Gain Do you smoke tobacco products? Yes, I smoke everyday Yes, I smoke occasionally No, I'm a former smoker No, I've never been a smoker Family History - Blood Relatives Check all that apply Amblyopia Blurred Vision - Far Blurred Vision - Near Burning Eyes Cataracts Double/Distorted Vision Drooping Eyelid Dry Eyes Eye Surgeries Eye Turn Floaters/Spots Fluctuating Vision Foreign Body Sensation Glaucoma Glare/Light Sensitivity Headaches Itchy Feeling Infection of eye/lid Loss of Vision - Central Loss of Vision - Side Mucus/Discharge Redness Retinal Detachment Tearing/Watery Eyes Physician / General Practitioner Physician Name Phone Last Medical Exam Date Medications Enter all medications taken, and for which condition each is taken Medication Condition 1 2 3 4 5 6 7 8 Allergies Enter all medications or substances to which the patient is allergic Please answer the following questions Are you pregnant or nursing? Yes No Do you have trouble driving at night? Yes No Do you wear glasses? Yes No Do you wear contacts? Yes No Do you experience blur, headaches, or eyestrain with computer use? Yes No Are you interested in laser (refractive) surgery to correct your vision? Yes No Vision Insurance Information Insurance Company ID Number Group Number Patient's relationship to insured Self Spouse Child Other Primary Insured's Sex Male Female Name of the Insured Insured's Phone Number Insured's Date Of Birth Other Insurance Information Insurance Company ID Number Group Number Patient's relationship to insured Self Spouse Child Other 2nd Insured's Sex Male Female Name of the Insured Insured's Phone Number Insured's Date Of Birth Additional Comments Is there anything else we should know? Let us know below. Powered By Terms Privacy © Copyright 2021