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.
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 Medical History
Have you ever had or experienced (Please check all that apply)

BlindnessCataractCrossed EyesGlaucomaMacular DegenerationRetinalDetachment/DiseaseArthritisCancerDiabetesLupusHeart DiseaseHigh Blood PressureKidney DiseaseLiver DiseaseThyroid ProblemsNeurological Disorders
Other illnesses:
Eye Care Appointment Preference*
Will you need transportation to your Eye Care appointment?*

YesNoN/A - I prefer to be seen in-home if possible
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.
Signature*

Clear
Should be Empty:

Patient Information