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Patient History Form

Welcome to the Office

Thank you for choosing our office. Please completely fill out this form to expedite your healthcare. We may ask you to update this information from time to time to ensure it remains up to date.
  • (if not English)
  • Insurance Information

  • Guarantor/Subscriber Information

    If patient is a minor or covered under the policy of a spouse, partner, parent, or guardian, please complete:
  • Primary Care Medical Doctor

  • (Rx or Over the Counter)
    Name of MedicationDose 
    Add a new row
  • Please list:
    Add a new row
  • SurgeryDate 
    Add a new row
  • Family Medical History and Relationship

  • Lifestyle

  • Pack/Day
  • Are you currently Pregnant or Nursing?
  • Contact Lens Wearers

  • Screeners

  • Optomap Retinal Imaging is recommended by the doctor as a screening tool for all patients. It gives the doctor a photo of the back of your eye, which provides more detail to your permanent record and adds a baseline for the doctor to compare to future examinations. Our other screening tool, Optical Coherence Tomography (OCT), gives a cross-section view of your retina, allowing the doctor to see anatomical changes that may otherwise be invisible from the front-view the doctor sees with other techniques. The OCT scan can detect macular degeneration and glaucoma changes earlier. The recommended optional screeners are $50.