Patient Information

Name*

Prefix First Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Please provide a telephone number, with area code, so we can contact you.

Daytime Phone

Cell Phone

Email Address

Please provide us your email address.

Personal Information

Gender*

Female
Male

Date of Birth*

Social Security Number (last 4 digits only!)

Please enter a number from 0000 to 9999.

Preferred Language*

Race*

Ethnicity*

Marital Status

Marital Status - Other

Please provide your marital status.

Occupation

How were you referred to our office?

Referral Status - Other

Please let us know how you were referred to our office.

Eye History

Please check off any current conditions you suffer from

Glasses History

Do you wear glasses?*

Yes
No

Contact Lens History

Do you wear contact lenses?*

Yes
No

What brand of contact lenses do you wear?

Medical History

When, approximately, was your last eye exam?

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 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

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Yes
No

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 State / Province / Region ZIP / Postal Code Country

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Comments

Privacy Policy

Health Information Protection*

I have read and agree to the Privacy Policy

Phone

This field is for validation purposes and should be left unchanged.