Name of Doctor you wish to see:
Today's Date
Today's Date
Name
Email Address
example@example.com
Home Phone
Male
Male
Female
Cel Phone
State
State
Zip Code
Work Phone
SSN
Fax Phone
Primary Care Physician
Previous Eye Doctor
Phone
Last Eye Exam
Referred By
Insurance
Cardholder
Address
City
Child
Child
Card Number or I.D.#
Group Number
Address:
Apt.#
Date of Birth
/
Month
/
Day
Year
Date
Spouse
Spouse
Other
Employer
Sports/Hobbies
Occupation
Emergency Contact
1 wear Glasses
1 wear Glasses
wear contact lenses
Soft
Hard
What brand of contact lens do you currently wear?
Yes
Yes
No
Medical History
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Ocular History
Medications
Injuries/ Surgeries
Blindness
Blindness
Cancer
Diabetes
Macular Degeneration
Heart Disease
High BloodPressure
Retinal Detachment
Kidney Disease
Crossed Eyes
Arthritis
Thyroid Disease
Currently pregnant or nursing.
Doesn't Drive
Drives
Doesn't Use Tobacco
Uses Tobacco
Other:
Driving Difficulties
Type/Amount/How Long?
Doesn't Drink Alcohol
Doesn't Drink Alcohol
Drinks Alcohol
Doesn't Use Illegal Drugs
Uses Illegal Drugs
Type/Amt/How Long
Gonorrhea
Gonorrhea
Hepatitis
Syphilis
HIV
Flashes
Flashes
Weight Loss/Gain
ormonalDysfunction
Vision Loss
Floating Spots
Fatigue
Drug Allergies
Fibromyalgia
Blurry Vision
Tired Eyes
Trauma
Asthma
Seasonal Allergies
Muscular Dystrophy
Distorted Vision
Cataracts
Lupus
Osteoarthritis
Double Vision
Diabetic Retinopathy
Eczema
Emphysema
Dryness
Glaucoma
Redness
Psoriasis
Anemia
Kidney Problems
Mucous Discharge
Hypertension
Bleeding Problems
Bladder Problems
Gritty Feeling
Headaches
Hypercholesterolemia
Leukemia
STD's
Itching
Colitis
Migraines
Burning
Crohn's Disease
Seizures
Allergies
Excess Watering
Ulcers
Mult. Sclerosis
Sinus Congestion
Light Sensitivity
Constipation
Eye Pain/Soreness
Diarrhea
Endocrine
Runny Nose
Runny Nose
Non insulin Diabetes
Post Nasal Drip
Chronic Infection
Insulin Diabetes
Chronic Cough
Sties
Fever
Thyroid Dysfunction
Dry Throat/Mouth
Name
First Name
Middle Initial
Last Name
Date of Birth:
/
Month
/
Day
Year
Date
Birth State:
Male
Female
Other (indicate)
RACE: (please circle one):
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Signature
Clear
Date:
/
Month
/
Day
Year
Date
Fax Line:
Website:
Date
/
Month
/
Day
Year
Date
Patient's/ Guarantor's Signature
Clear
INTIAL:
Patient or Guardian Name
Patient or Guardian Signature
Clear
Patient signature (Parent for minor)
Clear
Date
/
Month
/
Day
Year
Date
Patient Name:
Date:
/
Month
/
Day
Year
Date
Preferred Correspondence Address:
Preferred Phone Number:
Email Address:
example@example.com
No
Relationship:
DOB:
Name:
Phone:
Doctor:
Clinic:
Fax Line:
Print Name
Sign Name
Clear
Date
/
Month
/
Day
Year
Date
Patient Name:
DOB:
Patient/Guarantor Signature
Clear
Date
/
Month
/
Day
Year
Date
Date
/
Month
/
Day
Year
Date
Patient/Guarantor Signature
Clear
Patient Signature
Clear
(If guarantor is not the patient)
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type a question
Date
-
Month
-
Day
Year
Date
Type a question
Type a question
Type a question
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type a question
Type a question
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Type a question
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Type option 5
Type option 6
Type option 7
Type a question
Type option 1
Type option 2
This is a fill in the
blanks
field. Please add appropriate
blank
fields and text.
This is a fill in the
blanks
field. Please add appropriate
blank
fields and text.
Date
-
Month
-
Day
Year
Date
Signature
Clear
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
Clear
Date
-
Month
-
Day
Year
Date
Signature
Clear
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Type option 1
Type option 2
Type a question
Type option 1
Type option 2
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Type a question
Type a question
Type a question
Type a question
Date
-
Month
-
Day
Year
Date
Signature
Clear
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Signature
Clear
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Signature
Clear
Name
First Name
Last Name
Name
First Name
Last Name
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Appointment
Signature
Clear
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Type a question
Name
First Name
Last Name
Type a question
Type option 1
Type option 2
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Type a question
Preview PDF
Submit
Should be Empty: