Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name

Prefix

First

Last

Suffix

Address *

Street Address

City

State

Zip

Phone Number *

Daytime Phone

Cell Phone

Email Address

Personal Information

Gender *

Male

Female

Date of Birth *

Day

Month

Year

Social Security Number *

(last 4 digits only!)

Preferred Language *

Race *

Ethnicity *

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference

Eye History

Glasses History

Do you wear glasses? *

Yes

No

Other glasses:

Please tell us what other kinds of glasses you own.

How many hours a day do you use a computer?

How many inches away, approximately, do you sit from your computer monitor?

Please check off any current conditions you suffer from

I am having problems with my current glasses

There are times when I would rather not be wearing glasses

I have problems with glare

I have problems with night vision

I am allergic to nickel (e.g. frames of glasses)

I don’t have spare set of glasses

My spare glasses have an incorrect prescription

My sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Do you wear contact lenses? *

Yes

No

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

What is your typical wearing schedule? In days per week:

Please check off all that apply to you

I am having problems with my current contact lenses

There are times when I would rather not be wearing contact lenses

I am interested in changing or enhancing my eye color

I am interested in a non-surgical method of vision correction

I am interested in refractive laser surgery

I don't have a spare set of contact lenses

My spare contact lenses have an incorrect prescription

Medical History

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol?

Do you smoke?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list all hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all drug allergies you have

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insurance Company Phone Number

Address

Street Address

Address Line 2

City

Insured's Name

First

Last

Identification Number

Group Number

Insured's Date of Birth

Day

Month

Year

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Yes

No

Content

If you have coverage through another plan/organization, please fill in the details below.

Insurance Company Name

Insurance Company Phone Number

Address

Street Address

Address Line 2

City

Insured's Name

First

Last

Identification Number

Group Number

Insured's Date of Birth

Day

Month

Year

Patient's Relation to Insured

Comments

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