Request an Appointment

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 *

Address *

Phone Number *

Daytime Phone

Cell Phone

Email Address

Personal Information

Gender

Date of Birth *

Social Security Number (last 4 digits only!)

Preferred language *

Race *

Ethnicity *

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference

Eye History

Please check off any current conditions you suffer from
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Glasses History

Do you wear glasses?*

Contact Lens History

Do you wear contact lenses?*

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 drink alcohol?

Do you smoke?

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 hospital surgeries you have ever had:

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

Insurance Company Name

Insurance Company Phone Number

Address *

Insured's Name
Identification Number
Group Number
Insured's Date of Birth
Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

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