Please fill this out prior to your first appointment with us. Thank you!

Name*
Date of Birth
Email*
Phone*
Is texting OK?*
Home Address*

Emergency Contact*

Name*

Relation*

Phone Number*

Primary Insurance*

Insurance ID Number

Primary Insurance*

Primary Insured's Name + Date Of Birth

Secondary Insurance + ID Number (If Applicable)

Primary Care Physician

Main Reason For Upcoming Exam*

Last eye exam

Last physical exam

Are you pregnant or nursing?

Past or current illnesses or injuries

Past surgeries

Current medications*

Current eye drops

Allergies/sensitivities to medications or other*

Current Occupation

Do you smoke cigarettes?*

Do you drink alcohol?*

Do you use any illegal substances?*

Please check all current medical conditions you have or have been diagnosed with:
Please select all that apply

Other medical conditions please specify below:

Are you currently experiencing any of the following ocular symptoms:
Please select all that apply

Do you have a history of any of the following?*
Please select all that apply

Have you been diagnosed with any of the following?
Please select all that apply

Is there any family history of any of the following?
Please select all that apply

Have you ever worn glasses?*
Please select all that apply

Have you ever worn contact lenses?*

If you currently wear contact lenses, what type/brand of lenses do you wear?

Other Comments to share with office staff or Doctor

HIPAA POLICY: I agree to allow my medical information to be shared with my insurance company for the sole purpose of billing and to any healthcare provider necessary for continuity of care. I acknowledge that I am awaare that Optometric ASsociates, PC has a notice of privacy practices available to me at all times during normal business hours. I fully understand that I am protected under HIPAA and will be required to sign a release for any and all medical records. I*

OFFICE POLICY: In order to control the cost of billing we require that the patient's portion of costs is due at the time of services rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardlness of insurance. All accounts with unpaid bills after 90 days are subject to collection fees. There will be a service charge on all returned checks. We require at least 24 hours notice for any cancellations or rescheduled appointments in order to be fair to our other patients. Any late cancellations or missed appointments are subject to a $50 fee. I acknoledge and accept the above policies*

1 none 8:30 AM - 11:30 AM 1:00 PM - 4:30 PM 8:30 AM - 11:30 AM 1:00 PM - 4:30 PM 8:30 AM - 11:30 AM 1:00 PM - 4:30 PM 8:30 AM - 11:30 AM 1:00 PM - 4:30 PM 8:30 AM - 11:30 AM 1:00 PM - 4:30 PM Closed Closed optometrist # # #