Patient Form

Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.



Phone Number*

Email Address

Personal Information


Date of Birth*

Social Security Number (last 4 digits only!)

Marital Status​​​​​​​

Employment Status


How were you referred to our office?

Communication Preference

Eye History

Please check off any current conditions you suffer from

Glasses History

Do you wear glasses?*

Contact Lens History

    Medical History

    When, approximately, was your last eye exam?

    Where did you get your last eye exam?

    When, approximately, was your last physical exam?

    Who is your primary care physician?

    Do you drink alcohol?

    Do you smoke?

    Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

    Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

    Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

    Please list all hospital surgeries you have ever had:

    Please list all prescription and over-the-counter medications you take and for what conditions

    Please list all drug allergies you have

    Please check off any current conditions you suffer from

    Primary Insurance

    Please bring all insurance cards with you to your appointment.

      Insurance Company Name

      Insurance Company Phone Number


      Group Number

      Insured's Date of Birth

      Patient's Relation to Insured

      Secondary Insurance

      Do you have secondary insurance?


      If you have any comments you would like to add, please enter them here.

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