COVID-19 Information Have you or anyone in your home experienced a fever in the last 14 days?
No Yes
Have you traveled outside of our area in the last 14 days? If yes, where
No Yes
Patient Information
Personal Information Preferred Language*
English Spanish Japanese Decline to specify
Race*
American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other Decline to Specify
Ethnicity*
Decline to specify Hispanic or Latino Native Hawaiian or other Pacific Islander Not Hispanic or Latino
Marital Status
Single Married Divorced Legally Separated Widowed Other
Employment Status
Employed Full-Time Employed Part-Time Not Employed On Active Military Duty Retired Self-Employed Student Full-Time Student Part-Time Other
How were you referred to our office?
Friend or Family Family Doctor Ophthalmologist Insurance Company Newspaper Television Radio Received Mailing Internet Other Optometrist Other
Communication Preference
Email Postal Telephone
Eye History
Glasses History
Contact Lens History
Medical History 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 here or upload your file below
Please list all drug allergies you have
Please check off any current conditions you suffer from
Medical Insurance Please bring all insurance cards with you to your appointment.
Vision Insurance Please bring all insurance cards with you to your appointment.
Insurance Photos Please upload a copy of your insurance cards.
ID Please upload a copy of your ID.
Comments
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