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

Home Phone Number

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

Cell Phone

Email Address

Please provide us your email address.

Personal Information

Gender*

Female
Male

Date of Birth*

Occupation

How were you referred to our office?

Communication Preference*

Eye History

Please check off any current conditions you suffer from

Glasses History

Do you wear glasses?*

Yes
No

What glasses do you own?

Single Vision - distance
Readers
Bifocals
Progressive
Safety Glasses
Trifocals
Sports Glasses
Sunglasses
Other

Other glasses:

Please tell us what other kinds of glasses you own.

How many hours a day do you use a computer?

Please enter a number from 0 to 24.

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

Please enter a number from 0 to 120.

Contact Lens History

Do you wear contact lenses?*

Yes
No

What brand of contact lenses do you wear?

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:

Please enter a number from 0 to 24.

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

Please enter a number from 0 to 7.

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 smoke?

Please litst any eye surgery you have had with the approximate date (year) and surgeon who performed the surgery.

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

Please list all drug allergies you have

Please check off any current conditions you suffer from

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

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Comments

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

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