Patient Information Form

Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Sex

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Last 4 of your SSN

Format: 0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Exam History

Date of last examPlace of last exam

Reason for Today's Eye Exam

Other

Ocular History

Do you wear glasses? If so, select all that apply.

Are you interested in contacts?

Do you currently wear contacts?

If yes, please select wear schedule:

Contact Lenses

Family Ocular History: Do any of your parent, grandparents, or sibling have any of the following? (Select all that apply)

Health History

Do you smoke?

Please select the option that apply to your smoking habits:

Do you consume alcohol?

Average number of alcoholic drinks per week?

List out allergies

List all major surgeries

List all current medication

Medical Insurance Provider

Medical Insurance Card (front)

Medical Insurance Card (back)

Vision Insurance Provider

Vision Insurance Card (front)

Vision Insurance Card (back)

Are you pregnant or nursing?

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.

Signature

Date

How did you hear about our office?