Welcome to the Office
Please fill out as completely as possible, and let our staff know of any questions.
General Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Employer
*
Occupation
*
Primary Phone #
*
Please enter a valid phone number.
Secondary Phone #
Please enter a valid phone number.
Email
*
example@example.com
Preferred Method of Contact
*
Phone
Text
Email
Insurance Information
VISION INSURANCE
Name of Insurance
*
Policy/ID #
*
Are you the Primary Insured?
*
Please Select
Yes
No
If not Primary Insured - Name of Primary
*
Relationship to Primary Insured
*
MEDICAL INSURANCE
Name of Insurance
*
Policy/ID #
*
Are you the Primary Insured?
*
Please Select
Yes
No
If not Primary Insured - Name of Primary
*
Relationship to Primary Insured
*
Reason for Visit
Why are you here today? (ex: contact lenses, eye problems, new glasses, routine exam, etc.)
*
How did you hear about us? insurance website, friend, family(please list name), social media
*
Does your work require special vision needs?
*
Yes
No
Do you have persistent dryness in your eyes?
*
Yes
No
Interested in corrective laser surgery?
*
Yes
No
Interested in eliminating glasses without surgery?
*
Yes
No
Medical History
Please list any medical conditions now or in the past:
*
Please list current medications (incl. birth control, hormones, eye drops, supplements):
*
Name of Primary Care Physician
*
Phone #
*
Please enter a valid phone number.
Date of Last Physical
*
-
Month
-
Day
Year
Date
Anything else We should know about?
*
Medical Systems Review
*
Yes
No
Family (whom?)
Allergies
High Blood Pressure
Heart Disease
Diabetes
Gastrointestinal(Digest.)
Cancer
Endocrine/ Thyroid
Ear-Nose-Throat
Headaches
Urinary
Blood/ Lymph Nodes
Respiratory/ Lungs
Infectious
Ocular History/Symptoms
*
Yes
No
Blurred Vision
Double Vision
Tired When Reading
Spots
Cataracts
Eyelid Problems
Glaucoma
Tearing
Surgery
Trauma
Heavy Computer Use
Active Sports/Hobbies
Other
*
Submit
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