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EYE HEALTH & MEDICAL HISTORY

Welcome!  We look forward to your upcoming appointment and thank you for taking the time to provide the requested information which will be used to prepare your patient record.

For your convenience, electronically submitting your completed forms prior to your appointment bypasses the need to do this task on the day of your visit.  We NEVER sell or share any of your information with anyone at any time.  All information is transmitted via a secure network to ensure confidentiality, in compliance with the Health Privacy Laws.

We look forward to being of service to you!

 

First Patient's Name

First Name*

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Occupation / Student Grade

To better understand & address your visual demands, please specify your current OCCUPATION or STUDENT GRADE/LEVEL *
First Patient's Signature*
Second Patient's Name

First Name*

Last Name*
Second Patient's Date of Birth*
Second Patient's Occupation / Student Grade

To better understand & address your visual demands, please specify your current OCCUPATION or STUDENT GRADE/LEVEL *
Third Patient's Name

First Name*

Last Name*
Third Patient's Date of Birth*
Third Patient's Occupation / Student Grade

To better understand & address your visual demands, please specify your current OCCUPATION or STUDENT GRADE/LEVEL *
Fourth Patient's Name

First Name*

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Occupation / Student Grade

To better understand & address your visual demands, please specify your current OCCUPATION or STUDENT GRADE/LEVEL *
Fifth Patient's Name

First Name*

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Occupation / Student Grade

To better understand & address your visual demands, please specify your current OCCUPATION or STUDENT GRADE/LEVEL *
Sixth Patient's Name

First Name*

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's Occupation / Student Grade

To better understand & address your visual demands, please specify your current OCCUPATION or STUDENT GRADE/LEVEL *
Seventh Patient's Name

First Name*

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's Occupation / Student Grade

To better understand & address your visual demands, please specify your current OCCUPATION or STUDENT GRADE/LEVEL *
Eighth Patient's Name

First Name*

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's Occupation / Student Grade

To better understand & address your visual demands, please specify your current OCCUPATION or STUDENT GRADE/LEVEL *
Ninth Patient's Name

First Name*

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's Occupation / Student Grade

To better understand & address your visual demands, please specify your current OCCUPATION or STUDENT GRADE/LEVEL *
Tenth Patient's Name

First Name*

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's Occupation / Student Grade

To better understand & address your visual demands, please specify your current OCCUPATION or STUDENT GRADE/LEVEL *
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Eye Examination History
When was your last eye exam?*
Reason for Exam:*
Last Dilated Eye Exam:*
Eye Health History
I have undergone the following Eye Treatment(s): *
Eye Lid Surgery
Eye Muscle Surgery
Other Eye Treatment (discuss during exam)
Refractive / LASIK Surgery
Vision Therapy
None of the above
I have been diagnosed with the following Eye Condition(s): *
Cataracts
Glaucoma
Macular Degeneration
Previous Eye Injury (discuss during exam)
Retinal Detachment
None of the above
Medical Health History
I am being treated for the following Medical Health Condition(s): *
Diabetes
High Blood Pressure
High Cholesterol
Thyroid Disease
Cancer
Pregnancy
Other (discuss during exam)
None of the above

Medication List: Many medications prescribed as well as over the counter, have side effects that affect the eyes. Please list all medications currently used.

Allergy List: Please list all known sensitivities.

Comments / Concerns: Please indicate any concerns you may have that were not addressed in the form above.

*If you are scheduled for a CONTACT LENS EXAM & are NEW to our practice, please return to the FORMS tab on our website (www.seedryee.com) and kindly fill out the following:

  • CONTACT LENS AGREEMENT
  • CONTACT LENS EXPERIENCE
We look forward to being of service to you.  Thank you!

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Occupation / Student Grade

To better understand & address your visual demands, please specify your current OCCUPATION or STUDENT GRADE/LEVEL *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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