Online Intake Form Today’s Date MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY Patient Name First Middle Last Are you interested in Eyeglasses Sunglasses Computer/Reading glasses Are you interested in Contact lenses? If so please know that a contact lens exam/fitting is additional, elective & usually not fully covered by vision care plans(insurance). A contact lens exam/fitting ranges from $80 to $150 & more for specialty contact lenses. If you are not sure, speak with the doctor about your contact lens requirements. Permission to do contact lens exam Yes, I want a Contact Lens Exam/Fitting No, and I will not receive a contact lens prescription. Permission for Retinal Photo Yes $30.00 No I want to discuss that with the doctor Needed yearly if have diabetes or other eye disease, otherwise every 2 yearsResponsible Party SignatureMEDICAL HISTORY / CONDITIONS / MEDICATIONS Respiratory Asthma Cardiovascular High Blood Pressure High Cholesterol Endocrine Diabetes Thyroid Disease Hormone Replacement Immunologic Allergies Skin Condition Neurologic Psychiatric Musculoskeletal Ears, Nose, Mouth, Throat Gastrointestinal Genitourinary Blood Disease / Lymphatic Disease Significant loss or gain of weight in the last year Recurrent fever within last year Other Please Check All That ApplyOther Please list your specific diagnosis(s) from above Add RemoveIf DiabeticLast Blood Sugar Measurement Date MM slash DD slash YYYY Last a1c Measurement Date MM slash DD slash YYYY List All Medications You Take Add RemoveList All Medications You are Allergic to Add RemoveList All EYE Disease, Injuries or Surgeries you have had Add RemoveList immediate family member and their medical conditions Add RemoveList immediate family member and their eye disease Add Remove
