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 Name Middle Name Last Name
E-mail (if none, put "none" *
example@example.com
Date of Birth *

Month Day Year
Gender *

Female Male
Occupation *
Contact Number: *

Area Code Phone Number
Phone Type *

Cellphone Home phone Work phone
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
In case of emergency...
Emergency Contact: *

First Name Last Name
Relationship *
Contact Number *

Area Code Phone Number
How did you hear about us? *

Internet Search Insurance Panel Yelp Walk By Word of Mouth Family/Friend My Primary Care Doctor Returning patient
Who may we thank for referring you?
How would you like to be reminded of future appointments? *

Text Email Phone Call Post Card
Insurance Plans
What is your vision insurance plan? *

None (Private pay) VSP Eyemed MES Spectera Tricare I'm not sure
What is your medical/health insurance plan? *

I will not be using insurance/Not Applicable I don't have medical insurance Blue Cross Blue Shield Anthem Cigna United Health Care Tricare Medicare I'm not sure
ID number for Medical Insurance
ID number for Vision Plan
Are you the primary member on the insurance plan? *

Yes No Not applicable
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*
I consent that my insurance will be billed for my visit. If my insurance does not pay, I understand that I will be responsible for all charges. *

Yes I consent I will not be using insurance for today's visit.
Health History
Date of your last physical (approximate)
Name of your Primary Care Physician

Medical History

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

Ocular History

	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? *

Blurry distance/near Burning eyes Dry eyes Red eyes Itchy eyes Floaters/flashes Eyestrain/headaches Double vision None
Do you have medication allergies? *

Yes No
List medication allergies
Do you take any medications? *

Yes No
Please list all medications or please bring a copy of your medication to your visit.
I would like to learn more about:

Contact lenses Free LASIK consultation Dry eye therapy Near-sightedness/myopia control (ortho K)
COVID Questionnaire

	NO	YES
Have You Traveled outside the United States in the last 14 days?
Have you had contact with anyone with confirmed COVID-19 in the last 14 days?
Have you had any of these symptoms in the last 14 days? Fever greater than 100, Difficulty breathing, Cough
Are you currently experiencing fever over 100, difficulty breathing or cough?

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). *

Yes I agree No
All patients must wear a face mask at their visit. Only patients (and guardian) will be allowed in the exam room, family members/drivers without appointments will be asked to wait in the reception area. *

Yes I agree
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.) *

Clear
Should be Empty:

Patient Medical Intake Form

Insurance Plans

Health History

COVID Questionnaire

Patient Notice