About Us
Meet our Staff
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Patient Forms
Step
1
of
10
10%
Identifying Information
Title
*
Mr.
Mrs.
Ms.
Dr.
First Name
*
Nickname
Middle Initial
Last Name
*
Date of Birth
*
MM slash DD slash YYYY
Last 4 Digits of Social Security #
*
Marital Status
Married
Single
Divorced
Widowed
Contact Information
Email
*
Enter Email
Confirm Email
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Work Phone
Cell Phone
*
Insurance Information
Do you have insurance?
*
Yes
No
Insurance Name
Insurance ID #
Subscriber's Full Name
First
Last
Subscriber's Date of Birth
MM slash DD slash YYYY
Last 4 Digits of Subscriber's Social Security #
Employment and Activities
Employer
Occupation
Hobbies/Sports
Computer Use
Please enter a number from
0
to
24
.
Hours per day
How did you hear about our office?
Resposible Party
Are you the responsible party?
*
Yes
No
Please provide the following information about the responsible party.
Name
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Last 4 Digits of Social Security #
Eyecare Profile
Date of Last Eye Exam
MM slash DD slash YYYY
Do you wear glasses?
*
Yes
No
How often do you wear glasses?
*
Always
Occasionally
Distance
Reading
Do you wear contact lenses?
*
Yes
No
Interested
How often do you wear contacts?
Hours per day
Lens Type
Cleaning Solution
Any problems with your contact lenses?
Vision History
Check if you have had any of the following:
Blurry Vision - Near
Blurry Vision - Far
Eye Injury
Eye Infection
Eye Surgery
Colorblind
Retinal Problems
Cataract
Flashes/Floaters
Lazy Eye
Headaches
Watery Eyes
Burning Eyes
Itchy Eyes
Other
Please describe any other conditions:
Family History
Please indicate if any family member has / had any of the following by entering their relation to you.
Cataract
Glaucoma
Blindness
Diabetic Retinopathy
Macular Degeneration
Retinal Detachment
Medical Care Information
Primary Care Doctor
Doctor Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Doctor Phone
Last checkup date
MM slash DD slash YYYY
Current Medications
Allergies
(Seasonal/Medications)
Medical History
Check if you have / had any of the following:
AIDS/HIV
Anemia
Arthritis
Asthma
Cancer
Epilepsy
Hay Fever
Heart Condition
Hepatitis
High Blood Pressure
Migraine Headaches
Rheumatic Fever
Shingles
Stroke
Thyroid Condition
Diabetes
Kidney Disease
Emphysema
Lupus
Liver Disease
Currently Pregnant
Tuberculosis
Chemical Addiction
Alchohol use
Tobacco use
How many drinks do you have per day?
*
Please enter a number greater than or equal to
0
.
How many cigarettes do you smoke each day?
*
Please enter a number greater than or equal to
0
.
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