Intake Form

First Name

Last Name

MI

Date of Birth

Marital Status

Gender

Female Male

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Work Phone

Cell Phone

Email Address

Previous Patient

Yes No

Referred By:

Employer

Occupation

Race

Ethnicity

Height

Weight

Primary Policy Holder:

Relationship to Patient:

Insured's Date of Birth

Vision Insurance

Identification Number

Group Number

Other Insurance

Other Insurance Identification Number

Other Insurance Group Number

Last eye exam?

Doctor's Name:

Have you ever worn contact lenses?

Yes No

If no, are you interested in contact lenses?

Yes No

If yes, what brand do you wear?

How often do you change your lenses?

Do you sleep in your contacts?

Yes No

Any other ocular conditions:

Any family history of glaucoma and/or macular degeneration?

Yes No

If yes, who?

Current eye medications

Do you currently wear glasses?

Yes No

Age of current glasses

Do you wear sunglasses?

Yes No

Are you interested in LASIK?

Yes No

Last Medical exam:

Doctor's Name:

All medications you are currently taking:

Other allergies:

Are you currently pregnant/nursing?

Yes No

Do you smoke?

Yes No

If yes, how much

I have read and understand the above, and agree to the Retinal Imaging

Signature:

Date

I understand that this office is HIPPA compliant and acknowledge that the HIPPA policies are available upon request.

Signature:

Date

Intake Form

Patient Information

Insurance

Ocular And Contact Lens History

Medical History

Review Of Systems

Retinal Imaging

Hipaa Privacy Acknowledgment Of Notice Of Privacy Practices

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Intake Form

Patient Information

Insurance

Ocular And Contact Lens History

Medical History

Review Of Systems

Retinal Imaging

Hipaa Privacy Acknowledgment Of Notice Of Privacy Practices

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