Get Patient Information Form

Filling out the Patient Information Form online is a straightforward process designed to gather essential information about you or your dependent. This guide provides step-by-step instructions to ensure your experience is seamless and efficient.

Follow the steps to complete the Patient Information Form online

1. Click ‘Get Form’ button to access the Patient Information Form and open it in your preferred document editor.
2. Begin by entering today's date in the designated field at the top of the form.
3. Fill in your last name, first name, and middle initial as applicable. Select your gender from the provided options.
4. If you are filling out the form for a minor, provide the Social Security Number of the parent or guardian. Otherwise, leave this section blank.
5. Enter your date of birth and age in the appropriate fields.
6. Provide your primary address, including city, state, and zip code.
7. Fill in your cell, home, work, and other phone numbers, followed by your email address.
8. Indicate your employer and occupation details.
9. If applicable, provide the name of your spouse or guardian.
10. Fill out the emergency contact information, including their name, phone number, and relationship to you.
11. Answer whether you are a new patient and specify how you were referred to the practice.
12. If you will be using insurance, complete all fields in the Insurance Information section, including the name of your vision and medical providers, and member identification details.
13. In the Personal Eye History section, indicate the reason for your visit and provide details about previous examinations, surgeries, or injuries.
14. Answer the questions regarding your eyewear, type of lenses, and overall eye health.
15. List any sports or hobbies you engage in as requested.
16. Continue to the Medical Information section, providing details about your last medical exam, medications, allergies, and hospitalizations.
17. Complete the Review of Symptoms and Family History section, answering yes or no to the listed health concerns.
18. Provide social history information, indicating use of tobacco or alcohol, and any exposure to certain diseases.
19. If you have any questions or concerns, mention them in the designated section.
20. Once all fields are completed, you can save your changes, download a copy, print the form, or share it as needed.

Take the next step towards your eye care by completing the Patient Information Form online today.