• Patient Intake Form

  • Appointment Date
     - -
  • Birth Date*
     - -
  • Sex*
  • Format: (000) 000-0000.
  • Emergency Contact Information

  •    Employer/Occupation .

  • Responsible Person / Insurance Policy Holder

  • MEDICAL INSURANCE PROVIDER

  • Medical Insurance Card (Front)
  • Medical Insurance Card (Back)

  • VISION INSURANCE PROVIDER

  • Vision Insurance Card (Front)
  • Vision Insurance Card (Back)
  • Check all that apply to you*
  • Do any of your parents, grandparents, or siblings have any of the following? (Select all that apply)*
  • List any chronic health problems you may have*
  • List all major surgeries*
  • List out all current medication*
  • List out allergies
  • Exam History
  • Do you wear glasses? If so, select all that apply.
  • Do you wear contacts?
  • If so, please select wear schedule:
  • Contact Lenses
  • Are you interested in contacts?*
  • Please select the option that apply regarding your smoking habits
  • Do you consume alcohol?

  • To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. I directly assign to the doctor all insurance benefits, if any, otherwise payable to me for services rendered.I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The doctor may use my health care information and may disclose such information to the insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

  • Date*
     - -
  • Should be Empty: