Target Optical

  • Patient Information

  • Account Responsible Information

    Information about person responsible for bill. Only need address if different than patients.
  • Date Format: MM slash DD slash YYYY
  • Insurance Information

    Type Insurance Company under Company Name. Eyemed patients have no ID #, VSP ID last 4 of primary SS #.
  • Date Format: MM slash DD slash YYYY
  • Medications

    If no medication used, go on to next section, BUT PLEASE LIST ANY YOU ARE TAKING.
  • NameDate Started 
  • Allergeries

    If NO Alergeries, go on to next section.
  • NameReactionSeverity 
  • General History

  • Ocular History

  • Patient's Health History

    Check all that apply, or "Negative" if the patient has none of the conditions listed
  • Family Health History

    (cancer, diabetes, heart, hypertension, thyroid, glaucoma, cataracts, macular degeneration, etc.)
  • DiseaseRelationshipDetails