Alamo Optometry

Name*

First Last

Preferred Name/Nickname

Salutation (Mr., Mrs., Ms., Dr., or other)*

Gender*

Birthdate*

Social Security Number

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone*

Work Phone (or Alternate Phone Number)

Name of Parent (if minor)

First Last

Have we examined other members of your family?*

Yes
No

How did you find out about our office?

Who may we thank for referring you to our office?

First Last

Name of Last Eye Doctor/Office

Date of Last Eye Exam

Name of Family Physician*

First Last

Date of Last Visit to Primary Care Physician

Occupation

Employer or School

Vision Insurance*

Vision Service Plan
Eyemed
Medical Eye Services
None

Subscriber Name*

First Last

*If no vision insurance, please enter none for the subscriber information.

Subscriber Birthdate*

Subscriber Social Security or Policy Number*

Medical Insurance Company*

Subscriber Name

First Last

Subscriber Birthdate

Policy ID or Member Number

If Medicare, is it a PPO, HMO, or Medicare Advantage?

If Medicare, list supplemental carrier and policy ID

Do you have routine eye exam benefits through your medical insurance?

Yes
No

Do You Wear Eyeglasses?*

Yes
No

Do You Wear Contact Lenses*

Yes
No

Are you planning to get eyeglasses/contacts at your visit?*

Yes
No

What is the primary reason for your visit?

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

What Is Your General Health Status?*

List All Medications You Are Taking*

Medication Allergies*

Are You Pregnant or Nursing?*

Yes
No

Do You Use Tobacco Products?*

Current
Previous
Never

Do You Drink Alcohol?*

Socially
Daily
Never

Patient General Health

Patient Eye Health*

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

Are there any other important health or eye/vision concerns?

I have read the HIPAA Notice of Privacy:*

I have read the Financial Responsibility Policy:*

Name

First Last

Date