Welcome to Our Office
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
What is your Gender?
Male
Female
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Today's Eye Exam
Want Glasses
Want Contact Lenses
Eye Health Check
Eye Injury
Right Eye
Left Eye
Both
None
Eye Turn or Lazy Eye
Right Eye
Left Eye
Both
Not Sure
None
Other
Glaucoma
Cataract
Macular Degeneration
Surgery
None
Explain any of the above:
Family Ocular History:
Glaucoma
Macular Degeneration
Lazy Eye or Eye Turn
Other
None
Explain:
Patient Medical History:
Diabetes
Heart Condition
High Blood Pressure
Thyroid Condition
Cancer
Other
None
Explain Above
Family Medical History:
Diabetes
Heart Condition
High Blood Pressure
Cancer
Other
None
Explain Above
Are you currently taking any medication?
*
Yes
No
Medication (List purpose of medication if unsure of name)
Do you have any medication allergies?
*
Yes
No
Not Sure
Are you pregnant or nursing?
*
Yes
No
Pupil dilation improves the doctor's ability to examine the inside structures of the eye for signs of disease. Dilation is recommended for first time eye exams, persons with certain health conditions such as diabetes and at regular intervals for all persons. The effect of the dilation drops will typically last 4-6 hours and will include sensitivity to light and the inability to focus up close. In some cases distance vision may also be blurred. We will provide disposable sunglasses for light sensitivity.
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ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES. I acknowledge that I have received or had available to me the office's Notice of Privacy Practices.
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