Shawnee Vision Source

Exam History

When Was Patient's Last Eye Exam?

Are you Interested In?

Does Patient Currently Wear Glasses?

Yes
No

How Often Does Patient Wear Glasses?

Does Patient Currently Wear Contacts?

Yes
No

Current Contacts Brand

Current Contacts Prescription

Reason for Patient's Visit

Name of Patient's Primary Care Physician

Primary Care Physician's Phone

Primary Care Physician's Address

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

Optical & Medical History

Has patient experienced, or been treated for, any of the following? Check all that apply.

Eye Conditions & Disorders

Medical Conditions

Other Medical Conditions

Family History

Has any of patient's family members experienced, or been treated for, any of the following? Check all that apply.

Medications & Vitals

Vitamins

Please indicate all recreational and over-the-counter vitamins.

Aspirin
Vitamin C
Vitamin D
Vitamin E
Omega-E/Fish Oil
Glucosamine
Antihistamine
Other Vitamins

Current Medications

List all medications and conditions being treated.

Medication Drug Allergies

Please include food, tape, latex, and dyes.

Is Patient Pregnant or Nursing?

Yes
No

Does Patient Smoke?

Yes
No
Never

How Many Packs Per Day?

Does Patient Consume Alcohol?

Yes
No

How Many Drinks Per Week?

All insurance information must be provided to our office 24 hrs prior to the appointment day in order for us to verify benefits. If information is not provided patient will be seen as a private pay patient.
All children under the age of 18 must be accompanied by a parent or legal guardian. If they are not we may need to reschedule the appointment.
I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any unpaid balance.
All patients must arrive no later than 20 min prior to their scheduled appointment time for pre-testing and to complete paperwork.

Please bring a list of all current prescribed or over the counter medication taken to your appointment.
Please bring all glasses and contact lens currently in worn to your appointment.

Consent*

I have read and consent to the above statement.

Post Title

Comments

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New Patient Form

Step 1 of 3

Patient Details

Contact Information

Demographics

Insurance Verification

Vision Insurance

Medical Insurance

Exam History

Optical & Medical History

Medications & Vitals