Tell Us About Yourself - Eye Care Intake Form

Patient Information
Patient Gender*
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*

First NameLast Name
Emergency Contact Name and Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient or Caregiver's E-Mail
example@example.com
Reason for seeing the doctor:*
Insurance Information*
If Other (HMO/PPO or Medicare Supplement Name)
Insurance Number
If Vision Plan
Vision Care Insurance Number
Patient's Primary Care Physician (Doctor)
Patient Medical History
BlindnessCataractCrossed EyesGlaucomaMacular DegenerationRetinalDetachment/DiseaseArthritisCancerDiabetesLupusHeart DiseaseHigh Blood PressureKidney DiseaseLiver DiseaseThyroid ProblemsNeurological Disorders
Other illnesses:
Eye Care Appointment Preference*
YesNoN/A - I prefer to be seen in-home if possible
YesNo
Appointment - Please schedule a preferred date of appointment at least 24-48 hours from today's date. The date and time that you select is not guaranteed. Intake will call to confirm the "actual visit/appointment day and time" once your insurance/form of payment is verified. - Fridays are reserved for mobile/in-home eye appointments.
Signature*

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Should be Empty:

Patient Information