Patient Medical Intake Form

Patient Medical Intake Form

Welcome to our office! We thank you for entrusting us with your eye care! Please fill the following form PRIOR to your visit. For returning patients, we require all information to be updated yearly.
PATIENT INFORMATION
Date of appointment

MonthDayYear
Date
Name

First NameLast Name
Birth Date

MonthDayYear
Biological Gender
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
How did you hear about us?

Other
INSURANCE
What type of vision plan will you be using?

Other
IF you are the primary on the insurance, we need to verify your insurance information. Please enter the last 4 digits of your SSN.
IF you are NOT the primary on the insurance: Please enter the (1) first and last NAME of the primary insurance holder, (2) their DOB and, (3) their last 4 digits of their SSN
What MEDICAL insurance do you have?

Other
APPOINTMENT INFORMATION
Reason for visit:

Other
OCULAR HISTORY
Are you experiencing any of the following (check all that apply):

Other
Are you interested in:

Other

Have you or your family been diagnosed with the following OCULAR/EYE conditions:

Have you or your family been diagnosed with the following MEDICAL conditions:

Are you taking medications?
If so, please list Medications below (if none, write none):
Do you have any allergies and/or allergies to medications?
Please list any allergies and reaction (if none, write none).
Please annotate any additional concerns that you would like the Doctor to address during your appointment:
Vision/Medical Insurance Financial Acknowledgement and Scheduling Policies
At Acute Vision Optometry, we believe you deserve the best eye care. Our goal is to always present you with the best eye care treatment options for your eye concerns and diagnosis. Please review the following carefully.
HIPAA Authorization
Contact Lens Evaluation

If you will be having a contact lens evaluation in addition to the glasses exam, please review our contact lens instructions/contract below.
Signature
Hit the SUBMIT button below and you are done! (No need to print)

Thank you for your patience and cooperation. We look forward to seeing you at your appointment!
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