Patient Information Form If you would prefer to print this form, please use this link. Patient InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Birth* Home PhoneWork PhoneCell Phone*Email* RaceAmerican IndianAsianPacific IslanderWhiteOtherEthnicityHispanic or LatinoNot Hispanic or LatinoPatient SSNEmployer (or School)Job Title (or Grade)Spouse's Name (or Parent's Name)Spouse's Work (or Parent's Work)Purpose of this VisitWere you referred to us? If so, who referred you?If not, how did you hear about us? Another Doctor Sign/Building Ad Yellow Pages/Other Directory Your Website Insurance List Newspaper/Radio/TV Other Patient Medical HistoryName of Family Physician?Date of Last Checkup What medical condition are you being treated for?Current Medication (Rx or Over the Counter)Are you allergic to any medications?YesNoIf so, what medication?Do you use alcohol?YesNoDo you use tobacco?YesNoSmoking StatusCurrentFormerNeverPatient Eye HistoryDate of Last Exam By Whom?Have you ever tried contact lenses?YesNoDo you currently wear contact lenses?YesNoIf so, what kind?What solutions do you use?Are you satisfied with the vision and comfort of you contact lenses?YesNoHave you ever experienced, been diagnosed or treated for any of the following? Blurry Vision Burning Cataracts Corneal Abrasions Crossed Eye/Eye Turn Double Vision Eye Infections Eye Injury Flash of Light Floaters/Spots Glaucoma Grittiness Headaches Iritis/Uveitis Itchiness Lazy Eye Macular Degeneration Occasional Dryness Retinal Detachment Sunlight Sensitivity Tearing Trouble seeing at night Uncomfortable Glasses Eye Surgery Other Eye Disorders Family Medical/Eye History (Check all that Apply) Cancer Diabetes High Blood Pressure Hyperthyroidism Hypothyroidism Cataracts Macular Degeneration Glaucoma Relation with CancerFatherMotherBrotherSisterSonDaughterMultipleRelation with DiabetesFatherMotherBrotherSisterSonDaughterMultipleRelation with High Blood PressureFatherMotherBrotherSisterSonDaughterMultipleRelation with HyperthyroidismFatherMotherBrotherSisterSonDaughterMultipleRelation with HypotheyroidismFatherMotherBrotherSisterSonDaughterMultipleRelation with CataractsFatherMotherBrotherSisterSonDaughterMultipleRelation with Macular DegenerationFatherMotherBrotherSisterSonDaughterMultipleRelation with GlaucomaFatherMotherBrotherSisterSonDaughterMultipleLifestyle QuestionsDo you… (check all that apply) …think you might benefit from thinner, lighter lenses? …have interest in trying the latest contact lens designs? …spend significant time outdoors? …have prescription sunwear? …prefer not to wear your glasses at times? …want information on Laser Vision Correction surgery? …have more than one pair of Rx eyewear? …have family members in need of eyecare? Insurance InformationPlease note that most insurance providers do NOT cover the Contact Service FeesDo you have Vision Insurance? Yes No Is your insurance through VSP or Metlife? Yes No Last 4 Digits of Primary SSNVision Insurance ProviderVision Insurance Phone NumberVision Insurance ID NumberPrimary Medical Insurance ProviderHIPAA PolicyPlease read through our HIPAA Policy Form by clicking here.Financial PolicyWe are committed to providing you with a great customer experience and are happy to verify insurance eligibility and benefits. However, this is never a guarantee of benefits as some insurance companies arbitrarily select certain services that they will not cover and/or must be medically necessary. It is your responsibility to understand the scope and limitations of your insurance policy and you are financially responsible for all charges rendered whether or not paid by your insurance. For medical care, if you have not met your deductible, we will collect half of your balance at the time of service. You will receive a bill for the balance after your insurance processes your claim unless other arrangements have been made. Any non-covered services or copays are due at the time of service. Contact lens exam services are not covered by most insurance. All contact lens follow ups must be completed within 90 days or a new exam will be necessary. * I acknowledge that I have had the opportunity to read over both the HIPAA and financial policies of Blink Eyecare and agree to their terms. Siganture (Please enter your full legal name)*Date* This iframe contains the logic required to handle Ajax powered Gravity Forms.