"*" indicates required fields


Patient Info


MM slash DD slash YYYY
Address*
What is your Gender?*
Vision insurances require social security number to determine eligibility. This information must be entered prior to your visit or you will experience a delay during the time of your visit. All parts of this form are secure and encrypted.

Eye History


Do you have/have you had any of the following

Medical History


Are you currently taking any medication?*
Do you have any medication allergies?*
Do you have any medication allergies?*
Check the conditions that apply to you:
Check the symptoms that you have experienced in the PAST 6 WEEKS
Do you use or do you have history of using tobacco?
Do you use or do you have history of using illegal drugs?
How often do you consume alcohol?

Family History


Does anyone in the family have:
Does Anyone in the Family Have:
Patient Date of Birth
*
This field is for validation purposes and should be left unchanged.