EYE EXAM

Please fill out the form bellow and hit SUBMIT. If you wish to send your Eye Exam via fax, please download this PDF, print it and send it to us.


Patient Form
PATIENT INFORMATION
Date:  


Patient Name:
Address:

Home Phone:
Cell Phone:
Email:

Birthdate:
Age:
Sex:
Male       Female

Patient Employer / School:


INSURANCE INFORMATION


Who is responsible for this account?
Relationship to patient:

Insurance Company:
Member ID #
Subscriber's Name:
Subscriber's Date of Birth:
Social Security #

Do you wear glasses?
Yes       No
If yes, how old is your present pair:


Are you wearing contact lenses?
Yes       No
Are you interested in wearing contact lenses?
Yes       No
Are you interested in Laser Vision Correction?
Yes       No
First Visit?
Yes       No

Any special Eye or Vision problems?
Yes       No
If yes, please explain:

Reason for today's visit:
How were you referred to our office:


MEDICAL HISTORY


Medical Dr.:
Last Visit Date:
Phone Number:

Do you have / have had:

Diabetes:
Yes       No
Type:
 
 
Medication:

High Blood Pressure:
Yes       No
Medication:

Heart Disease:
Yes       No
Kidney Problems:
Yes       No
Thyroid Problems:
Yes       No
Cancer:
Yes       No
Headaches:
Yes       No
Allergies:
Yes       No
Sinus Problems:
Yes       No


Doesn anyone in your family have medical and/or eye condition(s)?
Yes       No
If yes, please explain:


OCULAR HISTORY


Blurred Vision:
Yes       No
Double Vision:
Yes       No
Tired when reading:
Yes       No
Spots:
Yes       No
Macular Degeneration:
Yes       No
Cataracts:
Yes       No
Eyelid Problems:
Yes       No
Glaucoma:
Yes       No
Tearing:
Yes       No
Dry Eyes:
Yes       No
Crusty Eyelid:
Yes       No
Eye Injury:
Yes       No
LASIK/Prk/Pk:
Yes       No



I request that payment of authorized medicare benefits or other insurance be made either to me or on my behalf to Dr. .... for any services furnished me by that doctor. I authorize any holder of medical informations about me, to release to the health care financing administration and its agents, any information needed to determine these benefits or the benefits payable for related services. I am responsible for any charges not covered by my insurance company.