Lifetime Eyecare

Lifetime Eyecare

Secure Form

New Patient Form

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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 State ZIP Code
Primary Phone*
Mobile Phone*
OK to Contact Via Text Message?*
Email*
Preferred Contact Method*
Do You Have an Emergency Contact?*
- Yes
- No
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Demographics
Patient Occupation*
Patient Gender*
Patient Marital Status*
Patient Race, Ethnicity*
How Did You Hear About Our Office?*
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.