PATIENT INFORMATION
TODAY'S DATE:
*
-
Month
-
Day
Year
Date
NAME
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMAIL:
*
example@example.com
HOME PHONE
*
-
Area Code
Phone Number
WORK PHONE:
-
Area Code
Phone Number
CELL PHONE:
-
Area Code
Phone Number
AGE:
*
HEIGHT:
*
(for ex, 4 feet 11 inches)
WEIGHT:
*
GENDER:
*
FEMALE
MALE
REFERRING DOCTOR:
*
PRIMARY CARE PHYSICIAN (PCP):
*
SPECIALIST:
*
PREFERRED METHOD OF CONTACT
*
(please select)
Snail Mail
Email
Home Phone
Work Phone
Cell Phone
No Preference
CURRENT EMPLOYMENT / ACTIVITY
*
IF RETIRED, FORMER EMPLOYMENT:
EMERGENCY CONTACT PERSON AND PHONE:
*
SPOUSE'S NAME AND OCCUPATION:
*
FAMILY HISTORY:
VACCINATIONS: (check)
*
COVID
FLU
PNEUMO
SHINGRIX (2 SHOT)
SMOKING STATUS: (check)
*
NEVER
FORMER
CURRENT
QUITTING
MEDICAL HISTORY: (check)
*
DIABETES
HYPERTENSION
HEART ATTACK
PROSTATE
ASTHMA
COPD
OSTEOPOROSIS
TRANSPLANT
SEIZURE DISORDER
ANXIETY
STROKE
RHEUMATOID ARTHRITIS
Other
EYE RUBBING
NEVER
RARELY
FREQUENTLY
DAILY
PATIENT MEDICATIONS
ALLERGIES:
*
EYE DROPS - EYE - FREQUENCY
CURRENT MEDICATIONS - DOSAGE - FREQUENCY
MEDICATION USE WHICH MAY AFFECT VISION (check)
*
AMIODARONE
ETHAMBUTOL
FLOMAX
FOSAMAX
GABAPENTIN
MINOCYCLINE
PLAQUENIL
PREDNISONE
TAMOXIFEN
TOPAMAX
NONE OF THE ABOVE
PATIENT UPLOADS
UPLOAD YOUR PICTURE ID
Browse Files
Please upload a photo of your picture ID. Take a clear and well-lit photo of the front side only. NOTE: If you do not have access to a camera or phone, please bring a Picture ID to your appointment (not preferred).
Cancel
of
UPLOAD CURRENT MEDICAL INSURANCE CARD
Browse Files
Please upload a photo of your current medical insurance card. Take a clear and well-lit photo of the front and the back. NOTE: If you do not have access to a camera or phone, please bring a copy of your medical insurance card to your appointment (not preferred).
Cancel
of
Save for Later
Submit
DATE OF BIRTH:
*
-
Month
-
Day
Year
Date You Were Born
Should be Empty: