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New Patient Demographic Form
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Indicates required field
Name
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First
Last
Date of Birth
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Cell Phone Number
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Email
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Eyeglass History
When was your last eye exam?
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Within the last year
Within the last 2-3 years
More than 5 years ago
Never
Do you currently wear glasses?
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Yes
No
If yes, what do you wear them for?
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Do you currently wear sunglasses?
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Yes
No
What kind of sunglasses are they? (check all that apply)
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Prescription
Polarized
Non-prescription
Lifestyle History
What is your occupation?
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Do you use a computer, handheld device (smartphone, tablet, reader, etc.), or play video games?
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Yes
No
How many hours a day do you spend on these devices?
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0 hours
2- 3 hours
3- 6 hours
6- 9 hours
More than 9 hours
Do you currently wear sports/safety glasses?
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Yes
No
Please list all sports and hobbies
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Contact Lens History
Do you currently wear Contact Lenses?
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Yes
No
If you have never worn Contact Lenses before, that requires an Instruction and Removal which we are not performing at this time due to COVID-19 and the increased risk of exposure due to close contact between the Doctor and the Patient for this exam. If you are a New Wearer and need this instruction, we recommend you return to the office at a later date when the risk of exposure has lowered.
If you currently wear contact lenses, please answer the following questions:
What type of contact lenses are they?
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Soft Contact Lenses
Rigid Gas Permeable Lenses
Specialty Lenses
What brand do you wear?
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How often do you change your contacts?
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N/A
Daily
Every 2 Weeks
Every Month
Every 3 Months
Once a Year
What cleansing solution do you use?
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History of Your Eyes
Please check all that apply:
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Blurry Distance Vision
Blurry Near Vision
Headaches
Interrupted Sleep
Dry Eye
Double Vision
Cataracts
Glaucoma
Eye Injury
Eye Surgery
Floating Spots
Flashes of Light
Lazy Eye
Vision Blackouts
Retinal Detachment
Retinal Disease
Eye Pain
Other:
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Do any member of your family have the above eye conditions? Please Explain:
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Medical History
Please check all that apply:
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High Blood Pressure
Diabetes
Heart Conditions
Heart Surgery
High Cholesterol
Breathing Problems
Kidney
Liver
Thyroid
Stroke
Body Numbness
Arthritis
Lung Disease
None of the above
Other:
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Do any members of your family have the above medical conditions? Please Explain:
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Do you have a history of Cancer?
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Yes
No
Type of Cancer:
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Do you have family history of Cancer?
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Yes
No
If yes, please explain type and relation to family member:
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Please list all Medications:
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Please list all Allergies:
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Retinal Imaging:
We recommend that every patient have an image of their retina on file. This allows the doctor to assess year after year the continued health of your eyes. This procedure consists of capturing an image of the back part of the eye. This is NOT an X-ray or Ultrasound and nothing will touch your eye. This permanent record is very valuable in assessing the current health of your eye and for safeguarding the health of specific structures such as the Retina, Optic Nerve, Macula, and Blood Vessels.
This procedure is not covered by any vision plans and costs $39.
Would you like to have Retinal Imaging done during your exam?
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Yes
No
Insurance Disclaimer, Beneficiary Agreement
I understand that my vision provider/medical insurance companies may deny payment for the services received today based on deductibles, co-insurance, and eligibility. If payment is denied, I agree to be personally and fully responsible for payment. I also understand that if my vision provider/medical insurance company does not make payment for services, I will be responsible for any co-payment, deductible, or co-insurance that applies.
Type in your name verifying you read and understand the above. (Parent/Guardian's Name here is patient is under 18)
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Home
The Family
The Doctors
The Staff
In the Community
Testimonials
Insurance
Patient Forms
New Patient Demographic Form
My Medical Records
Resources
Retinal Imaging
Dry Eye Treatments
Blurry Near Vision
Contact Lenses
>
More Information for Contact Lens Wearers
Blue Light Exposure
Sports Eye Injury Prevention
Ocular Conditions
Frames
Lenses
