NEW PATIENT INFORMATION FORM

Please complete the information below and submit the form online, or if you prefer, print out the form after full or partial completion, and bring it when you come to our office.

* = required  
SELECT A PRACTITIONER
Doctor* Please select an item.
   
PERSONAL
Prefix*
First Name* <<< A value is required.
Last Name* <<< A value is required.
Address* <<< A value is required.
Address 2 <<< A value is required.
City* <<< A value is required.
State* / Zip* <<< A value is required.    <<< A value is required.
Home Phone* <<< A value is required.
Day Phone
Cell Phone
Pager
Fax
Email* <<< A value is required.Invalid format.
 
   
Gender* Please select an item.
Date of Birth* (mm/dd/yyyy) <<< A value is required. Please use MM/DD/YYYY format.
SS# (no dashes)
Marital Status
Employment
Employer
Occupation
How were you referred to our office?* Please select an item.
   
EYE HISTORY  

Please check any current conditions you suffer from.

I stopped wearing glasses because:

I stopped wearing contact lenses because:


Headaches
Glare/Light Sensitivity
Tired Eyes
Amblyopia (lazy eye)
Burning
Dryness
Watery Eyes
Eye Pain and/or Soreness
Foreign Body Sensation
Infection of Eye or Lid
Itching
Mucous Discharge
Drooping eyelid(s)
Redness
Sandy or Gritty Feeling
Strabismus (crossed eye)
Blurred Vision at Distance
Blurred Vision at Near
Haloes
Double Vision
Floaters or Spots
Fluctuating Vision
Loss of Vision
Loss of Side Vision

 
GLASSES HISTORY (skip if you don't wear glasses)
What Glasses do you own? Single Vision
Bifocals
Safety Glasses
Backup Glasses
Progressive
Trifocals
Sports Glasses
Sunglasses
Other
How many hours a day do you use a computer?
How many inches away, approximately, do you sit from your computer monitor?
Please check off any current conditions you suffer from.

I am having problems with my current glasses
There are times when I would rather not be wearing glasses
I have problems with glare
I have problems with night vision
I am allergic to nickel (e.g. frames of glasses)
I don’t have spare set of glasses
My spare glasses have an incorrect prescription
My sunglasses are missing UV (ultra-violet) protection

 
CONTACT LENS HISTORY (skip if you don't wear contacts)
What brand of contact lenses do you wear?
How old are your current lenses?
How often do you replace or dispose of your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule? Hours per day:   Days per week:
Please check off all that apply to you:

I am having problems with my current contact lenses
There are times when I would rather not be wearing contact lenses
I am interested in changing or enhancing my eye color
I am interested in a non-surgical method of vision correction
I am interested in refractive laser surgery
I don't have a spare set of contact lenses
My spare contact lenses have an incorrect prescription

 
MEDICAL HISTORY
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Do you drink alcohol?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.):
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy Eye, Retinal Detachment):
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High Blood Pressure, Cancer, Glaucoma, Macular Degeneration, etc.):
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions:
Please list all drug allergies you have: A value is required.
Please check off any current conditions you suffer from:

Chronic fever, unexpected weight loss/gain, fatigue
Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)
Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)
Respiratory problems (eg. Shortness of breath, wheezing, coughing)
Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)
Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)
Skin problems (eg. Rashes, excessive dryness, growths or lumps)
Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)
Psychiatric problems (eg. Depression, anxiety)
Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)
Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)
Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)

 
PRIMARY INSURANCE
Please bring all insurance cards to your appointment.
Insurance Company
Phone Number
Address
Insured's Name
ID Number
Group Number
Insured's Date of Birth
Insured's SS#
Patient's Relationship to insured
 
SECONDARY INSURANCE
Please bring all insurance cards to your appointment.
Insurance Company
Phone Number
Address
Insured's Name
ID Number
Group Number
Insured's Date of Birth
Insured's SS#
Patient's Relationship to insured
   
HIPAA PRIVACY POLICY
Health Information Protection* Please make a selection.I have read and agree to the HIPAA Privacy Policy
   

 

*required


 

To learn about some of our practice areas in detail please choose a link below:

Our optometrist (eye doctors) provide expert eye care and full service eye exams to the areas of Dacula, Buford, Auburn, Hamilton Mill, Gwinnett County, and Lawrenceville (GA).

Our Practice Areas include (other Eye Care Services):