Eye to Eye Family Eye Care

Name*

First Last

Birthdate*

Social Security Number

Email*

Sex

Marital Status*

Preferred Language

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Business Phone

Communication Preference

Name of Parent or Spouse*

First Last

Have we examined other members of your family?*

Yes
No

Employment Status

Occupation

Employer

Health Insurance Company*

Member Name*

First Last

Member DOB*

Member Number*

Vision Insurance:*

Vision Insurance Member Number:*

Name of Family Physician*

First Last

Emergency Contact:*

First Last

Emergency Contact Phone:*

How Did You Find Out About Our Office*

List All Medications You Are Taking*

Pharmacy Name

Pharmacy Phone Number

Medication Allergies*

List All Major Illnesses, Injuries, Surgeries In The Last 10 Years

Are You Pregnant?*

Yes
No

Date Of Last Eye Exam*

Do You Wear Eyeglasses?*

Yes
No

Do You Wear Contact Lenses*

Yes
No

Current Eyedrops, Prescription, and Over the Counter:*

List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries*

Family History (Family History includes your parents, grandparents, siblings, and your children)*

If Other, Please Define:

Do You Use Tobacco Products?*

Current
Previous
Never

Do You Drink Alcohol?*

Socially
Daily
Never

Patient Eye Health*

If Other, Please Define:

Patient General Health

If Other, Please Define:

Race*

American Indian or Alaskan Native
Asian
Black or African American
Hispanic
Native Hawaiian or other Pacific Islander
White

Ethnicity*

Hispanic or Latino
Native Hawaiian or other Pacific Islander
Not Hispanic or Latino

Reason for Visit:*

Retinal Photography

Retinal Photography: Our doctors recommend a retinal image for all patients over the age of 8. This technology provides a permanent digital record of the retina and important structures of the eye. Comparing these images on an annual basis allows for early detection and monitoring of eye disease. These photos can be provided to you or any future medical provider.

OCT (Ocular Coherence Tomography)

An OCT screening is able to detect the earliest signs of eye disease such as glaucoma and macular degeneration. Our doctors recommend that anyone over the age of 40 have a baseline screening performed and also recommend a screening to anyone over the age of 30 who has a family history of eye disease.

I would like to have both screenings performed today ($50)
I would like to have only the retinal photo performed ($30)
I would like to have only the OCT performed ($30)
I do not want any additional testing today

Eye to Eye Family Vision Care