Patient Information Save time and paper by filling out your information before coming in for your appointment. Your information is safe with us. First Name*Last Name*Your Date of Birth Please. MM DD YYYY PhoneEmail Address Street Address City ZIP Code EmployerOccupationDo you have vision insurance?YesNoPrimary Vision InsuranceHow did you hear about us?What are some of your hobbies?Medical HistoryYour last eye exam was on? MM DD YYYY Are you under the care of a physician?YesNoPlease provide us with your physicians name and phone.Are you taking any medications?YesNoPlease list all your medications.Are you allergic to any medications?YesNoPlease list the medications you are allergic to.Do you use a computer?YesNoHow many hours per day?123456+Please select any of the following that apply to you. I work with small print I work in the sun I use protective eyewear at work Diffculty with vision at arm's length Difficulty watching television Difficulty with near vision Sensitive to sunlight Sensitive to bright light I am a student I am active in sports I want contact lenses Eye InformationHave you ever had any eye conditions or problems?YesNoHave you ever had an eye injury?YesNoTell us a little bit about what happened and when.Have you had any eye operations?YesNoTell us about your operation and when it happened.Do you have any problems in any of these areas? Blood/Lymph Cardiovascular Ears/Nose/Throat Endocrine Gastrointestinal Headaches High Blood Pressure Immunologic Psychiatric Muscle/Bones Respiratory Skin Urinary Pregnant/Nursing Because you selected one or more of these problems can you provide a bit more information on your conditions?Family HistoryHas any immediate family member been disgnosed with any of the following? Glaucoma Macular Degeneration Retinal Detachment Crossed Eye Cataracts Diabetes Lupus Can you tell us whom in your family had Glaucoma?Select OneMotherFatherSiblingMaternal GrandparentPaternal GrandparentCan you tell us whom in your family had Macular Degeneration?Select OneMotherFatherSiblingMaternal GrandparentPaternal GrandparentCan you tell us whom in your family had Retinal Detachment?Select OneMotherFatherSiblingMaternal GrandparentPaternal GrandparentCan you tell us whom in your family was Crossed Eye?Select OneMotherFatherSiblingMaternal GrandparentPaternal GrandparentCan you tell us whom in your family has Cataracts?Select OneMotherFatherSiblingMaternal GrandparentPaternal Grandparent*Please read the Notice of Privacy Practices and Release of Identifying Health Information forms by clicking the bolded links and then check the boxes below. We will have the two forms for you to sign when checking into your appointment. Thank you. I have read and understood the Notice of Privacy Practices. I authorize for the Release of Identifying Health Information. This iframe contains the logic required to handle Ajax powered Gravity Forms.
