Family Vision Source
Secure Form
New Patient Form
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General Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
*
Mobile / Cell Phone
OK to contact via Text Message?
Yes
No
Email
Enter Email
Confirm Email
Preferred Contact Method
Primary Phone
Mobile Phone
Email
Post
Date of Birth
*
Preferred Language
English
Spanish
French
Japanese
Decline to Specify
Gender
*
Select One
Male
Female
Other
Marital Status
Select One
Single
Married
Divorced
Legally Separated
Widowed
Race
*
Select One
American Indian or Alaska native
Asian
Black or African American
Hispanic
Native Hawaiian/other pacific island
White
Decline to Specify
Other
Height
Weight
Ethnicity
*
Select One
Hispanic or Latino
Native Hawaiian/other pacific island
Not Hispanic or Latino
Occupation
Insurance
*
I have insurance
I do not have insurance
Exam History
Last Eye Exam
When was your last eye exam?
Currently Wear Glasses?
*
Yes
No
Currently Wear Contacts?
Yes
No
Current Contacts Brand
Current Contacts Prescription
Are you interested in Contacts?
Yes
No
Reason for your Visit?
*
Optical & Medical History
Have you experienced, or been treated for, any of the following? Check all that apply.
Primary Care Physician
Date of Last Medical Exam
Medical History
*
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
None of the Above
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
None of the above
Family History
*
Has any of your family members experienced, or been treated for, any of the following? Check all that apply.
Glaucoma
Diabetes
Macular Degeneration
Cataract
None of the above
Medications & Vitals
Current Medications
*
Medication Drug Allergies/Environmental Allergies
*
Are you pregnant or nursing?
*
Yes
No
Do you smoke?
*
Yes
No
Have you ever smoked?
Yes
No
If Referred by Family or Friend, Who May We Thank?
Name
This field is for validation purposes and should be left unchanged.