Patient Forms

0%

Personal & Contact Information

Full Name*

Nickname

Date of Birth*

Address*

Phone*

Email*

Employer

Referred By

Communication Preference*

Insurance

Vision Insurance

Insurance Company

ID Number

Last 4 digits of SSN

Primary Care Doctor

Doctor's Location

Policy Holder

Policy Holder's Date of Birth

Relationship to Policy Holder

Do you have another Vision Insurance to apply?

Insurance Company

ID Number

Last 4 digits of SSN

Primary Care Doctor

Doctor's Location

Policy Holder

Policy Holder's Date of Birth

Relationship to Policy Holder

Medical Insurance

Insurance Company

ID Number

Last 4 digits of SSN

Primary Care Doctor

Doctor's Location

Policy Holder

Policy Holder's Date of Birth

Relationship to Policy Holder

Do you have another Medical Insurance to apply?

Insurance Company

ID Number

Last 4 digits of SSN

Primary Care Doctor

Doctor's Location

Policy Holder

Policy Holder's Date of Birth

Relationship to Policy Holder

Health History

Reason for the visit

Eye Comfort Questions

I have allergies to the following medications

Other known allergies

Smoking Status*

Have you ever had any eye surgeries?*

I have been diagnosed with:

I have a family history of:

My vision is important for these activities

Other visual tasks important to you:

Macular Risk Assessment

AMD Risk Factors (check all that apply)

It is recommended that we measure your macular pigment density if you have checked off three or more risk factors. This simple test will help the Doctor determine your risk factor for Macular Degeneration and set up a prevention plan.*

Final Questions

Do you wear contact lenses?*

Are you interested in discussing Lasik?*

Is there anything else you want us to know about you or your eyes?