Online Patient Forms Demographics and Insurance Information Demographics and Insurance Information Cell PhoneWork PhoneDate of Birth MM slash DD slash YYYY Age SexMaleFemaleEmail SSN Occupation Employer Emergency Contact First Last PhoneRelationship of Emergency Contact to Patient New Patients Only: Name of doctor or referring party First Last Insurance InformationPrimary Insurance Carrier Secondary Insurance Carrier Responsible Party (if patient is a minor) To allow us to file for your medical insurance benefits and/or accept Medicare assignment, you will need to sign a release upon visiting the office. Please call us at (214) 522-2661 if you have any questions! Medical/Ocular History MEDICAL/OCULAR HISTORY Name First Last Date of Birth MM slash DD slash YYYY Date MM slash DD slash YYYY Drug Allergies Surgical HistoryCurrent MedicationsSmoking History*Current SmokerFormer SmokerNever SmokerMedical Conditions That Apply to You Arthritis Asthma Cholesterol Headaches Heart Disease High Blood Pressure HIV Lung Disease Rosacea Seasonal Allergies Seizures Shingles/Fever Blisters Stroke Thyroid Cancer Diabetes Other If Cancer was selected, please specify type: If Diabetes was selected, please provide most recent blood sugar count and date taken If Other was selected, please specify Eye Conditions that Apply to You (past and present): Cataract Color Blindness Corneal Disease Diabetes Double Vision Dry Eye Glaucoma Lazy Eye Macular Degeneration Retinal Detachment or Tear Other Glasses - How Long Eye Surgery LASIK/PRK RK Cataract Glaucoma Retina Cornea Transplant Surgery DetailsEye/medical conditions of your immediate family: Cataracts Glaucoma Diabetes Blindness Macular Degeneration Cornea Any other type of ocular disease Type of contact lenses you are wearing: Soft RGP Toric Multifocal Monovision How long to you wear one pair of contact lens: 1 Day 1-2 Weeks 1-2 Months Other Type of cleaning solutions used Any allergies to contact lens Any problems with current lenses
