Cornell Eyecare Group

Patient Information

All information will be confidential.

Patient Status*

NEW PATIENT
RETURN PATIENT

Name*

First Middle Last

Birthdate*

Email*

Address*

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

Home Phone

Cell Phone*

Business Phone

Marital Status*

What is your preferred method of communication?

Phone Call
Text
Email
Mail

Reason for today's visit*

(NEW Patients) Whom may we thank for referring you to our office?

Please list the name of family or friend that referred you.

Insurance Information

Social Security Number*

Visual Insurance Company*

ID/Policy Number*

Group Number*

Policy Holder Name*

First Last

Relationship to policy holder?*

Employer

DO YOU HAVE ADDITIONAL INSURANCE WE SHOULD BILL?*

Yes
No

Visual Information

Date Of Last Eye Exam*

Patient Eye Health*

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

Health Information

List All Medications You Are Taking*

Medication Allergies*

Have you had any significant changes in your health or any major health problems?*

Yes
No

If "yes", please explain.

Patient General Health

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

Do You Use Tobacco Products?*

Current
Previous
Never

Do You Drink Alcohol?*

Socially
Daily
Never

Lifestyle Factors

Your answers will assist us in selecting the best eyewear for you!

Occupation

Do you currently participate in any hobbies or outdoor activities?

Do you use a computer?

Yes
No

Do you drive long distances?

Yes
No

Do you like to watch TV?

Yes
No

Do You Wear Eyeglasses?*

Yes
No

Do You Wear Contact Lenses*

Yes
No

What brand or type are your current contact lenses? (Soft, Glass Perm, and Brand)

Signature*

Authorization - I certify that I have read, understand and answered the above information to the best of my knowledge. I consent for Cornell Eyecare to bill my insurance company.

Today's Date*