Envisionoptique - Welcome Form

Welcome to the Office

Please fill out as completely as possible, and let our staff know of any questions.
General Information
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer
Occupation
Primary Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact
Insurance Information
VISION INSURANCE
Name of Insurance
Policy/ID #
Are you the Primary Insured?
If not Primary Insured - Name of Primary
Relationship to Primary Insured
MEDICAL INSURANCE
Name of Insurance
Policy/ID #
Are you the Primary Insured?
If not Primary Insured - Name of Primary
Relationship to Primary Insured
Reason for Visit
Why are you here today? (ex: contact lenses, eye problems, new glasses, routine exam, etc.)
How did you hear about us? insurance website, friend, family(please list name), social media
Does your work require special vision needs?
Do you have persistent dryness in your eyes?
Interested in corrective laser surgery?
Interested in eliminating glasses without surgery?
Medical History
Please list any medical conditions now or in the past:
Please list current medications (incl. birth control, hormones, eye drops, supplements):
Name of Primary Care Physician
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Physical

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Anything else We should know about?

Medical Systems Review

Rows	Yes	No	Family (whom?)
Allergies
High Blood Pressure
Heart Disease
Diabetes
Gastrointestinal(Digest.)
Cancer
Endocrine/ Thyroid
Ear-Nose-Throat
Headaches
Urinary
Blood/ Lymph Nodes
Respiratory/ Lungs
Infectious

Ocular History/Symptoms

Rows	Yes	No
Blurred Vision
Double Vision
Tired When Reading
Spots
Cataracts
Eyelid Problems
Glaucoma
Tearing
Surgery
Trauma
Heavy Computer Use
Active Sports/Hobbies

Other
Should be Empty:

Welcome to the Office

General Information

Insurance Information

VISION INSURANCE

MEDICAL INSURANCE

Reason for Visit

Medical History