Home
About
Services
Contact
Welcome Form
Home
About
Services
Contact
Welcome Form
Welcome Form
Please fill out and submit this form to get started. Or just stop by!
Patient Information:
Name
*
First Name
Last Name
Date of Birth
Sex
Address (Street, City, State, Zip)
Home Phone
Cell Phone
Email
First Choice Contact Method
Home Phone
Cell Phone
Text
Email
Second Choice Contact Method
Home Phone
Cell Phone
Text
Email
SSN
Employer (or School)
Occupation (or Grade)
Spouse (or Parent) Name
Spouse (or Parent) Work
What is the major purpose of this visit?
*
Any problems with current contact lenses or glasses?
*
Very Important! New Patients Only:
Who may we thank for referring you to our office?
If not referred, how did you choose our office?
Another Doctor
Insurance List
Saw Sign/Building
Newspaper
Radio
TV
Yellow Pages
Web Site
Other
Insurance Information
Vision Insurance
Vision Insurance Subscriber Name
Vision Insurance Subscriber SSN
Vision Subscriber Birth Date
Primary Medical Insurance
Primary Subscriber Name
Primary Subscriber SSN
Primary Subscriber Birth Date
Do you participate in flex spending account?
Yes
No
How will you settle your account?
Cash
Check
Credit Card
Lifestyle Questions
Do you.... (Check all that apply)
Work at a computer?
Think you might benefit from thinner, lighter lenses?
Have an interest in "test drive" of latest contact lens designs?
Spend time outdoors?
Have prescription sunwear?
Prefer not to wear glasses at times?
Play any sports?
Have hobbies that may require unique eyewear/lenses?
Have more than one pair of current Rx eyewear?
Have children?
Have family members in need of eyecare?
Have you ever experiences, been diagnosed, or treated for any of the following ocular conditions?
Blurry vision
Cataracts
Crossed eye/eye turn
Eye infections
Flash of light
Glaucoma
Headaches
Itchiness
Macular degeneration
Retinal detachment
Tearing
Uncomfortable glasses
Burning
Corneal abrasions
Double vision
Eye injury
Floaters/spots
Grittiness
Iritis/Uveitis
Lazy eye
Occasional dryness
Sunlight sensitivity
Trouble seeing at night
Any other eye disorders?
Patient Medical History
Name of Family Physician
Town of Family Physician
Date of Last Physical
CURRENT MEDICATIONS: Please list Rx or over-the-counter medications, including eye drops, vitamins, and birth control pills
Allergies to any medications?
Yes
No
If so, which medications?
Have you had any surgeries?
Yes
No
Do you use cigarettes/tobacco, alcohol, or other substances?
Yes
No
Have you ever been diagnosed or treated for the following health problems?
Allergies
Arthritis
Blood/Lymph
Bronchitis
Cancer
Cholesterol
Diabetes
Digestive
Ears/Nose/Throat
Endocrine
Eczema/Rashes
Fatigue
Fevers
Genitourinary
High Blood Pressure
Ingumentary (Skin)
Kidney
Muscle/Bone
Nerological
Psychological
Respiratory
Sinus
Throat Infections
Thyroid
Unusual Weight Loss/Gains
Patient Eye History
Date of Last Eye Exam
By whom?
Have you ever tried contact lenses?
Yes
No
Do you currently wear contact lenses?
Yes
No
What kind of contact lenses?
Solution used?
Are you satisfied with the vision and comfort of your contact lenses?
Yes
No
Would you prefer clear contact lenses or colored contact lenses?
Clear
Colored
If you wear bifocals, do the lines or head tilting bother you?
Option One
Option Two
Family Medical/Eye History
Is there a family medical history of any of the following (check all that apply)
Blindness
Cataracts
Corneal Problems
Diabetes
Glaucoma
Heart Disease
Lazy Eye
Macular Degeneration
Retinal Problems
DISCLAIMER AND ELECTRONIC SIGNATURE
I HAVE READ AND UNDERSTAND THE CONSENT FORM AND CONSENT TO THE USE AND DISCLOSURE OF MY HEALTH INFORMATION FOR THE PURPOSE OF TREATMENT, PAYMENT, AND HEALTH CARE
Dated
Patient Electronic Signature
Patient Guardian Electronic Signature
If patient's guardian is signing, please describe your relationship
Thank you!
