Referring Doctors

Last Name :

Date :

Address :

Home Phone :

Business Phone :

Employer :

Birth Date :

Sex :  Male Female

Medical Primary Insurace Type & ID :

Medical Secondary Insurace Type & ID :

Vision Insurace Type & ID :

Reason for your office visit today : (Check all that apply) Lost or broken eyeglasses Want new glasses Want new contact lenses Yearty eye exam Problems with current contact lenses Eyes water Eyes ltch eyes feel dry Pain in eyes Headache Eyestrain Droopy eyetid Eyes burning Eyes feel tired spots or floatersrflashes Double Vision Sensitive to light other

Personal Medical History : (Check all that apply to YOU)  High, Blood Pressure Diabetes Heart Disease Thyroid HIV/AIDS Blindness Glaucome Cataracts Lazy Eye Refractive Surgery Eye Surgery Eye Injuries Retenal Problems Blood Transfution other

Family Medical History: (Check all that apply to immediate family members)  High Blood Pressure Heart Disease Diabetes Cancer Stroke Blindness Glaucomo Cataracts Retinal Disorders Age related Macular Degeneration other

Social History :  Do you Smoke No Yes 1-5 Per day 1Pack/day More Do You Drink No Yes 1 Per day 2-3/Week More

Current Medications :

Are you pregnant :  Yes No

If yes, month

First Name :

social Security #(optional) :

City :

State :

Zip :

Cell Phone :

Email Adress :

Occupation :

Age :

List activities in which you participate

Computers : How many hours per day?

Sports :

Hobbies :

Allergies to contact lens solutions :  Yes No

lf yes, which ones:

"While we will make every effort to verify and confirm your insurance, it is your responsibility to understand the terms and conditions of your insurance. Payment for co-pays and non-insured seryices are expected at the time of service. Thank you for allowing us to serye your eye care needs"

Patient Signature/Legal Guardian :