New Patient Forms

To save time on the day of your appointment, please fill out the following form and click the submit button
at the bottom. Your information will be transmitted via a secure connection.
You may also download, print, and fill out a paper copy here.

First Name:
Last Name:
Date of Birth:
Gender: Male     Female
Zip Code:
Home Phone:
Work Phone:
Cell Phone:

Please check all that apply:
Allergies to Eye Drops History of Cataract Cataract Surgery Glaucoma Eye injury
Floaters Macular degeneration Retinal tear Retinal detachment
Pterygium Strabismus Lazy Eye Blepharitis Dry Eyes
Scratch on eye Corneal ulcer Cornea transplant Previous LASIK

Please list any other past eye problems below:

Please check all that apply:
Diabetes High blood pressure High cholesterol Heart attack Seizure disorder
Asthma COPD Chronic bronchitis Seasonal allergies Sinus infections
Arthritis Rheumatoid arthritis Lupus Sjogrens Syndrome Gout
Heartburn Irritable bowel Anemia Bleeding disorder Gallbladder disease
Depression Anxiety Overactive thyroid Low thyroid Migraines

Please list any other past medical problems below:

Please list all surgical procedures you have had below:


Please list all EYEDROPS that you currently use:

Please list all OTHER MEDICATIONS that you currently take:

Please list any ALLERGIES to medications that you have:

Please check all symptoms that you have had within the last month.

General Health: Weight loss Weight gain Fatigue Loss of appetite
Eyes: Blurred vision Loss of side vision Itching/Burning Double vision
  Dry eyes Eye pain Crusting/Discharge Eye strain
  Haloes Glare Headache Trouble reading
Ears: Ear pain Hearing loss Ringing in ears Dizziness
Nose/Throat: Runny nose Nasal congestion Sore throat Trouble swallowing
Heart/Lungs: Chest pain Shortness of breath Coughing Wheezing
GI: Heartburn Nausea/Vomiting Abdominal pain Diarrhea
Urinary: Blood in urine Increased urination Difficulty urinating Pain with urination
Musculoskelatal:     Back pain Pain in muscles/joints Limited range of motion
Skin: Rash Sores Changing moles
Neurological: Seizures Weakness/Numbness Memory problems Loss of coordination
Blood: Easy bruising Nosebleeds Swollen hands/feet Blood transfusion
Immune: Seasonal allergies Swollen glands Previous STDs HIV infection
Mental Health: Depression Anxiety Mood swings

Please check all that apply:
   Use tobacco products
   Drink alcohol
   Wear RGP contacts
   Wear soft contacts

Please check all that apply to someone in your family:
   Cataract surgery prior to age 50
   Macular degeneration
   Retinal detachment
   Corneal dystrophy

   Heart disease
   High blood pressure
   Sickle cell anemia