Lifetime Eyecare
Secure Form
New Patient Form
Step
1
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3
33%
Patient Details
Patient Name
*
First
Last
Patient Date of Birth
*
Is the Patient a Minor?
*
No
Yes
Legal Guardian Name
*
First
Last
Contact Information
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
*
Mobile Phone
*
OK to Contact Via Text Message?
*
Yes
No
Email
*
Preferred Contact Method
*
Primary Phone
Mobile Phone
Email
Do You Have an Emergency Contact?
*
Yes
No
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Demographics
Patient Occupation
*
Patient Gender
*
Select One
Male
Female
Other
Patient Marital Status
*
Select One
Single
Married
Divorced
Legally Separated
Widowed
Patient Race, Ethnicity
*
Select One
Caucasian
African American/Black
Hispanic/Latino
Asian
Middle Eastern
Pacific Islander
Native American/Alaskan
Other
How Did You Hear About Our Office?
*
Select One
Insurance Provider
Internet Search
Doctor Referral
Friend Referral
Website
Other
Who May We Thank for Referring You?
*
Insurance
*
I have insurance
I do not have insurance
Insurance Verification
Last Four Digits of Patient's Social Security Number
Vision Insurance
Do you have Vision Insurance?
*
Yes
No
Vision Insurance Provider
*
Vision Insurance Member Name
*
Vision Insurance Member ID#
*
Vision Insurance Member Date of Birth
*
Medical Insurance
Do you have Medical Insurance?
*
Yes
No
Name of Medical Insurance Provider
*
Medical Insurance ID#
*
Medical Insurance Policy or Group ID#
*
Medical Insurance Member Date of Birth
*
Medical Insurance Member Employer
*
Relationship to Medical Insurance Member
*
Spouse
Child
Exam History
When Was Patient's Last Eye Exam?
*
Does Patient Currently Wear Glasses?
*
Yes
No
How Often Does Patient Wear Glasses?
*
Constantly
Reading / Computer
Driving
Leisure / Fashion only
Does Patient Currently Wear Contacts?
*
Yes
No
Current Contacts Brand
*
Current Contacts Prescription
*
Are You Interested in Contacts?
*
Yes
No
Reason for Patient's Visit
*
Name of Patient's Primary Care Physician
*
Optical & Medical History
Has patient experienced, or been treated for, any of the following? Check all that apply.
Eye Conditions & Disorders
*
Cataracts
Crossed Eye
Glaucoma
LASIK or RK
Lazy Eye
Macular Degeneration
Retinal Detachment
Blurry Vision (Near or Far)
Burning
Discharge
Double Vision
Dryness
Excess Tearing/Watering
Eye Infection
Eye Pain or Soreness
Floaters or Spots
Halos
Headaches
Itching
Light Flashes
Light Sensitivity
Redness
Sandy or Gritty Feeling
Other
None
Medical Conditions
*
AIDS/HIV
Allergies
Arthritis
Asthma
Blood/Lymph Disorder
Cancer
Diabetes
Ears, Nose, Throat Conditions
Gastrointestinal Conditions
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Lupus
Neurological Conditions
Psychiatric Disorder
Seizures
Skin Conditions
Stroke
Thyroid Dysfunction
Other
None
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.
Arthritis
Amblyopia
Stroke
Glaucoma
Thyroid Disease
High Blood Pressure
Diabetes
Cancer
Lupus
Kidney Disease
Macular Degeneration
Retinal Detachment
Cataract
Blindness
Other
None
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
None
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?
*
1
2
3
4
5 +
Social
Does Patient Consume Alcohol?
*
Yes
No
How Many Drinks Per Week?
*
1
2
3
4
5 +
Social
Several procedures are required to examine the health of your eyes and determine treatment and/or the prescription for your eyewear. The comprehensive examination generally requires the instillation of eye drops to dilate the pupil of the eye. Dilating drops allow the doctor to examine the structures inside of the eye. These drops may result in light sensitivity, hazy vision and difficulty focusing at near, for duration of four (4) to eight (8) hours. Please exercise caution while, operating equipment, or reading during the duration of these effects.
*
I acknowledge the importance of dilating drops and understand the effects on my vision. I wish to ACCEPT the use of DILATING EYE DROPS
I have read and understand the information on the Optomap retinal screening and accept responsibility for the additional payment of $39. I wish to ACCEPT the OPTOMAP RETINAL SCREENING.
Information on Optomap Retinal Screening
I elect to have BOTH the Optomap retinal screening AND the OCT done for the payment of only $45. I have read and understand the information on the OPTICAL COHERENCE TOMOGRAPHY (OCT).
Information on Optical Coherence Tomography
Phone
This field is for validation purposes and should be left unchanged.