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
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
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25
26
27
28
29
30
31
Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
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1978
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1974
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1972
1971
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1968
1967
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
Please Select
United States
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
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
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*
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.
*
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
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)
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
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
Submit
Should be Empty: