San Marino Optometry Intake

Patient Medical Intake Form

Please fill in the form below prior to your visit. For returning patients, we require all information to be updated yearly.
Name

First NameMiddle NameLast Name
E-mail (if none, put "none"
example@example.com
Date of Birth

MonthDayYear
Date
Gender
Occupation
Contact Number:

Area CodePhone Number
Phone Type
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
How did you hear about us?

Other
Who may we thank for referring you?
How would you like to be reminded of future appointments?
Insurance Plans
What is your vision insurance plan?

Other
What is your medical/health insurance plan?

Other
ID number for Medical Insurance
ID number for Vision Plan
Are you the primary member on the insurance plan?
If not, provide the name of the primary insurance holder, their DOB and last four of their SSN
Last four digits of your SSN *optional, this allows us to verify VSP/Eyemed insurance benefits*
Insurance / Managed Care Financial Acknoledgement
I authorize payment for my vision and or medical benefits be paid directly to the Doctor. I agree that if my employer, insurance carrier, or plan sponsor denies payment of all or any portion of my claim, I will be financially responsible for all outstanding charges. Authorization obtained at time of service does not guarantee payment.
Health History
Date of your last physical (approximate)
Name of your Primary Care Physician

Medical History

Rows	Self	Family	Both	None
Diabetes
Pre-diabetes
Hypertension
High Cholesterol
Thyroid disorder
Heart Condition
Cancer
None
Other

Ocular History

Rows	Self	Family	Both	None
Lazy Eye
Cataracts
Glaucoma
Macular Degeneration
Eye Surgery
Eye Injury
LASIK/Refractive surgery
Retinal Disease
None
Other

Date of last eye exam (approximate)
Name of your last eye doctor
Do you experience any of the following?

Other
Do you have medication allergies?
List medication allergies
Do you take any medications?
Please list all medications or please bring a copy of your medication to your visit.
I would like to learn more about:

Other
Patient Notice
I consent that exam records such as (referrals, reports, medications Rx, glasses/contact lenses prescription) can be sent to me digitally (via email).
Please read our privacy policy and sign below.
I have read and agree to the office's privacy policy. (Parents/guardian please sign for minor.)
Should be Empty:

Patient Medical Intake Form

Insurance Plans

Insurance / Managed Care Financial Acknoledgement

Health History

Patient Notice