Patient Form

GENERAL INFORMATION

Last*

First*

Middle Initial*

Preffered Name*

City*

State*

Zip*

Phone*

Phone 2

Email Address*

Preferred Contact Method*

Other Preferred Contact Method

Patient Social Security Number*

Date of Birth*

Gender*

Occupation/Employer

Marital Status*

Language

Race

Ethnicity

Emergency Contact Person Name

Emergency Contact Person Phone

INSURANCE INFORMATION

Vision Insurance

Vision Insurance Member Name

Vision Insurance Member ID#

Vision Insurance Member Date of Birth

Primary Medical Insurance

Primary Member Name

Insurance ID#

Insurance Policy#/Group ID#

Primary Member Date of Birth

Primary Member Social Security Number

Your Relationship to Primary Member

Other relationship to Primary Member

Secondary Medical Insurance

Secondary Medical Insurance Member Name

Secondary Medical Insurance ID#

Secondary Medical Insurance Policy #/Group ID#

Secondary Medical Insurance Member Date of Birth

Secondary Medical Insurance Member Social Security Number

Your Relationship to Secondary Medical Insurance Member

EYE HISTORY

Date of Last Eye Exam

Currently Wear Glasses?

Currently Wear Contacts?

Reason for Today’s Visit

Have you or a family member experienced, or been treated for, any of the following? Check all that apply.

Cataracts

Crossed Eye

Glaucoma

LASIK or RK

Lazy Eye

Macular Degeneration

Retinal Detachment

Are you currently experiencing, or have experienced, any of the following? Check all that apply​​​​​​​

MEDICAL HISTORY

Have you or a family member experienced, or been treated for, any of the following? Check all that apply.​​​​​​​

AIDS/HIV

Allergies

Arthritis

Asthma

Blood/Lymph Disorder

Cancer

Diabetes

Ears, Nose, Throat Conditions

Gastrointestinal Conditions

Heart Disease

High Blood Pressure

High Cholesterol

Kidney Disease

Lupus

Neurological Conditions

Psychiatric Disorder

Seizures

Skin Conditions

Stroke

Thyroid Dysfunction

Current Medications (prescription and over-the-counter and dosage)

Medication Drug Allergies​​​​​​​

Height

Weight

Are you pregnant or nursing?​​​​​​​

Do you smoke?​​​​​​​

Have you ever smoked?

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