Please complete the information below and submit the form online or, if you prefer, print out the form after completion and bring it when you come to our office.

This form contains confidential information that is delivered to your doctor through a secure Internet connection.

Patient Information

Are you a new or existing patient?*

New Patient
Existing Patient

Name*

Prefix First Last Suffix

Preferred Nickname

Address*

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

Communication Preference*

Phone Number*

Daytime Phone

Cell Phone

Email Address

Personal Information

Gender*

Female
Male

Date of birth*

Social Security Number (last 4 digits only!)

Driver's License or State Identification number

Race*

Ethnicity

Preferred Language

Occupation

Employer

How were you referred to our office?

Eye History

When, approximately, was your last eye exam?

Where did you get your last eye exam?

Have you ever been diagnosed with any eye conditions*

Yes
No

Please list any eye conditions you have ever been diagnosed with (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please check any conditions you suffer from currently

How many hours per day are you in front of a computer?

Please enter a number from 0 to 24.

Glasses History

Do you wear glasses?*

Yes
No
I stopped wearing glasses

I stopped wearing glasses because:

What type of glasses do you own?

Distance only
Reading only
Workstation
Lined Bifocals or Trifocals
No-line or Progressive
Sunglasses
Sports
Safety
OTC Readers

Please check any current issues with your glasses.

There are times when I'd rather not wear my glasses
I have problems with glare or night driving
I get headaches while reading or working at the computer
My frames turn green or corrode easily
I don’t have a second set of glasses
My sunglasses don't seem to offer much protection
It's time for some new glasses

Contact Lens History

Do you wear contact lenses?*

Yes
No
I stopped wearing contact lenses

I stopped wearing contact lenses because:

How old are the contact lenses you are currently wearing?

What brand of contact lenses have you been wearing?

What brand of solution do you clean your lenses in?

How often do you use your contact lenses?

Everyday
A few days a week
Special occasions
For sports/ working out only

When do you discard your contact lenses?

Daily
Every 2 weeks
Monthly
When they feel bad

Please check all that apply to you

My current contact lenses are uncomfortable
I have blurred vision in my current contact lenses
I am interested in changing or enhancing my eye color with contact lenses
I am completely out of contact lenses
My current contacts are too expensive
I'm interested in another brand of contacts

Medical History

When, approximately, was your last physical exam?

Who is your primary care physician?

Are you diabetic?*

Yes
No

When were you diagnosed?

Have you ever been diagnosed with any other medical conditions?*

Yes
No

Please list any other medical conditions you have ever been diagnosed with (High blood pressure, Arthritis, etc.)

Please check any medical conditions you currently suffer from

Please list any surgeries you've had:

Are you currently taking any medications?*

Yes
No

Please list all prescription and over-the-counter medications you're currently taking*

Are you allergic to any medications?*

Yes
No

Please list any drug allergies you have*

Do you smoke?

Do you drink alcohol?

Please list any family history (blood relatives) of medical or ocular conditions (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Medical Insurance

Do you have Medical Insurance?*

Yes
No

Insurance Company's Name*

Member's Name*

First Last

Who's insurance is the patient under?

Identification Number*

Group Number*

Member's Date of Birth*

Patient's Relation to Insured Member

Vision Insurance

Do you have vision insurance?*

Yes
No

Insurance Company's Name*

Member's Name*

First Last

Who's insurance is the patient under?

Identification Number or Last 4 digits of Member's SSN*

Group Number

Member's Date of Birth*

Patient's Relation to Insured Member

Comments

If you have any comments you would like to add, please enter them here.

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Health Information Protection*

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Comments

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Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Medical Insurance

Vision Insurance

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