Paperwork

1
Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Area Code
Phone Number
3
Email* This field is required.
example@example.com
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Gender* This field is required.
Male
Female
6
Please upload a copy of your Drivers LicenseYou can take a quick photo with your phone and upload it here. We will need to see your ID again once you arrive for your exam. Please have it ready.
Drag and drop files here
Select files to upload
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7
Date of Birth* This field is required.
Date
Year
Month
Day
8
Reason for Your Exam* This field is required.What brings you in this year to see us?
ie - Yearly Eye Exam, Contact Lens Renewal, My eyes are red...
9
When was your last eye exam? (If you are not sure, your best guess is helpful)* This field is required.
Date
Month
Day
Year
10
How did you hear about us?
11
Do you have any allergies? If yes Please List all.* This field is required.
Type "none" if no allergies
12
List Any Medications that you are currently taking?* This field is required.
If none type "none"
13
Do you engage in Regular Exercise?* This field is required.
Yes
No
14
Do you Smoke?* This field is required.
Yes
No
15
Do you use recreational drugs?* This field is required.
Yes
No
16
Do you Drink Alcohol?* This field is required.
YESNO
17
Do you have a History of the following? (Please check all that apply)* This field is required.
Blindness
Blurred Vision
Burning/Itching
Cancer
Cataracts
Chronic Eye Infections
Crossed eyes
Diabetes
Double Vision or Prism
Dry eyes
Excessive Tearing
Eye Allergies
Eye Pain/Soreness
Eye Surgery
Flashes/Floaters
Glare/Light Sensitivity
Glaucoma
Halos
Headaches
Heart Disease
High Blood Pressure
Kerataconus
Loss of Vision
Macular Degeneration
Mucous Discharge
Red Eyes
Retinal Detachment
Retinal Problems
NONE
Other
18
Paternal History: Does your biological father have a history of?* This field is required.
Blindness
Blurred Vision
Burning/Itching
Cancer
Cataracts
Chronic Eye Infections
Crossed eyes
Diabetes
Double Vision or Prism
Dry eyes
Excessive Tearing
Eye Allergies
Eye Pain/Soreness
Eye Surgery
Flashes/Floaters
Glare/Light Sensitivity
Glaucoma
Halos
Headaches
Heart Disease
High Blood Pressure
Kerataconus
Loss of Vision
Macular Degeneration
Mucous Discharge
Red Eyes
Retinal Detachment
Retinal Problems
NONE
Unknown
Other
19
Maternal History: Does your biological mother have a history of?* This field is required.
Blindness
Blurred Vision
Burning/Itching
Cancer
Cataracts
Chronic Eye Infections
Crossed eyes
Diabetes
Double Vision or Prism
Dry eyes
Excessive Tearing
Eye Allergies
Eye Pain/Soreness
Eye Surgery
Flashes/Floaters
Glare/Light Sensitivity
Glaucoma
Halos
Headaches
Heart Disease
High Blood Pressure
Kerataconus
Loss of Vision
Macular Degeneration
Mucous Discharge
Red Eyes
Retinal Detachment
Retinal Problems
NONE
Unknown
Other
20
Report the Frequency of dry eye symptoms you are experiencing: Dryness, Grittiness, Scratchiness* This field is required.
0 = Never
1 = Sometimes
2 = Often
3 = Constant
21
Will you be using Insurance during your visit? * This field is required.If Yes, please provide as much detail as possible so we can provide a seamless appointment. Leaving info out may cause a delay in authorizing your insurance and providing timely service.
YESNO
22
What is the Name of your HEALTH Insurance Company?Your Health Insurance plan and your vision plan are USUALLY different.
BCBS - Blue Cross & Blue Shield
UHC - United Health Care
Cigna
Kaiser
Humana
Other
23
What is the name of your VISION Insurance Company or Plan?
Eyemed
Blue View
Davis
Spectera
VSP (Vision Service Plan)
Superior
VCP (Vision Care Plan)
Other
24
Is the patient the primary insurance account holder?
YESNO
25
Primary on Insurance Policy
First Name
Last Name
26
Primary Contact Information
Area Code
Phone Number
27
Primary's EmployerWhat company does the Primary member work for?
28
Primary's Date of Birth
Date
Year
Month
Day
29
Relationship to Patient
Spouse/Partner
Parent/Caregiver
Self
Other
30
What is your Vision Insurance ID# or Last four of your SSN?Many insurances use your SSN as your ID number, this is need prior to your exam so we can verify that you have benefits available to use.
31
Please upload a copy of your insurance card here. You can take a quick photo with your phone and upload.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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32
Do you wear eyeglasses?
YESNO
33
How many years have you had this pair of glasses?
1 Year or Less
2 Years
3 Years
4 Years
More than 4 years
34
How do you like the Vision out of your Eyeglasses?
The Distance could be better
The Intermediate/Computer Range could be better
Reading could be better
The vision in my current glasses is just how I like them.
35
If you have a copy of your last eyeglasses prescription, please upload it here. This will let you know if there have been any changes since your last exam.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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36
Do you wear Contact Lenses?* This field is required.
I have NEVER Worn Contact Lenses
I wore contact lenses before in the past but not now.
I currently wear contact lenses
Other
37
Do you wear hard or soft lenses?
Hard
Soft
Hybrid/Synergy Material
I'm not sure
Other
38
What Brand of Contact Lenses do you Wear?
Acuvue
Air Optix
Biofinity
Clariti
Dailies
ProClear
Freshlook
Soflens
Clariti
BioTrue
AquaSoft
Zen
Synergize
Novakone
Scleral
Other
39
How often do you dispose of your contact lenses and put in a new pair?
Daily
Weekly
2 Weeks
Monthly
Month and a Half
2 Months
About 6 Months
Over 6 Months but not a year
Yearly
40
How often do you sleep in your contact lenses?
Every night
Several times a week
A few times a month
A few times throughout the year
I never sleep in my contact lenses
41
Please Check ALL that Apply: My contact lenses...
Are Comfortable
Are Uncomfortable
Dry out too easily
Tear easily
Hard to keep up with
Cause my eyes to burn, itch, or cause redness
are hard to see distance with
are hard to read with
are hard to see my computer with
42
If you have a copy of your last CONTACT LENS prescription, please upload it here. This will let you know if there have been any changes since your last exam.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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43
On average, how many hours a day do you spend on an electronic device? This includes cell phone, tablets, kindles, and other electronic devices.* This field is required.
1
2
3
4
5
6
7
8
More than 8
44
Pupil Dilation: Do you have time during your visit to be dilated?* This field is required.Dilation is an important part of your exam and allows the eye doctor to provide a thorough examination.
Yes
No
I will decide and speak with the Doctor
Should be Empty: