In efforts to serve you most efficiently, please complete the information below and submit the form online, or if you prefer, print it out and bring it with you when you come into our office.  If you have any questions about any of the questions, simply leave blank questions you don't know the answer to...we'll help take care of that when you arrive :-)

Name (first, last)	*
Salutation		Mr. Mrs. Ms. Miss. Dr.
Address:	*
City:	*
State:	*
ZIP:	*
Date of Birth (mm/dd/yyyy)	*
Phone (Cell):	*
Phone (Home):	*
Phone (work)
SS#:
Email:
Who May We Thank For Referring Your To Our Clinic?
check one		Friend or Family member Family doctor Opthalmologist Insurance company Received a mailing Internet Search Engine Yellow Pages Newspaper Other
Primary Insurance Information
Insurance Company Name
Employer
Identification Number
Group Number
Name of Policy Holder
Insured Date of Birth (mm/dd/yyyy)
Insured SS#
Secondary Insurance Information
Insurance Company Name:
Identification Number
Group Number
Patient's Relation to insured:
Insured D.O.B. (mm/dd/yyyy)
Insured's SS#:
How Will You Settle Your Account Today?
Payment method:	*	Cash Check Visa/MC/Discover
Do you/your employer participate in a Medical Flex Spending Account?		Yes No
Medical History
Check All That apply		Allergies Asthma Arthritis Cancer Diabetes HighBlood Pressure Cholesterol HIV Heart Disease Skin Disorder Lazy Eye Eye Disease Eye Surgery Cataracts Glaucoma Macular Degeneration Retinal Detachment LowVision
Current Medications
Medications		AntiHistamines Diuretics (water pill) Blood Pressure Oral Contraceptive Sleeping Tablets Eye Drops Other
Eye Experience(s)		Burning Tearing Itching Redness Swelling Discharge Clear Discharge Mucous Nausea Fainting or dizziness Blurred Far Visioin Blurred Near Vision Blurred Computer or Cell phone vision Sensitivity to Light Sensitivity to Air Watery Eyes Dry Eyes Gritty or Sand Feeling in the Eyes Headaches Flashes Floaters Reading Problems Learning Problems Double Vision Glare or Halo Problems Night vision problems Other
Do You...		Work at a computer for long periods Have more than one pair of eyeglasses Wear Bifocals if yes, are you bothered by head tilting, restricted areas of vision with them Spend a lot of time outdoors Have prescription computer glasses Have prescription sunglasses have problems with glare reflection and or halos Are there times you would rather not wear glasses
Have You Ever Worn/Are You currently wearing contacts lenses
contact lens		Yes No
Are you interested in contacts Lenses?		Yes No
Are you interested in Laser Eye Surgery?		Yes No maybe, can I have more information?
Name of Family Physician:
Security Code	*