Focused Eye Care

Please note our updated cancellation policy.

Patient Details

Patient First Name

Patient Last Name

Patient Date of Birth

Is the Patient a Minor?

No Yes

If patient is a minor, please enter the name of the legal guardian

Contact Information

Address

Street Address

Address Line 2

City

State

Zip Code

Primary Phone

Are we able to send text messages to this number?

Yes No

Email address

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

Demographics

Patient Occupation

Please type alternate pronouns here if applicable

How did you hear about our office?

Insurance Verification

Last Four Digits of Patient's Social Security Number

Required to determine insurance eligibility

Vision Insurance

IF SELECTING OTHER/UNSURE, PLEASE CALL THE OFFICE TO CONFIRM THAT WE ARE IN NETWORK WITH YOUR VISION PLAN (847)243-8176

I understand and will call

Vision Insurance Member Name

Last Four Digits of Vision Insurance Member's Social Security Number

Vision Insurance Member's Date of Birth

Vision Insurance Member ID# (If Applicable)

Medical Insurance

Primary Card Holder Name

Medical Insurance ID number

Medical Insurance Policy or Group ID#

Medical Insurance Member Date of Birth

Medical Insurance Member Employer

Relationship to Primary Medical Insurance Member

Self Spouse Child Other

Do you have a secondary medical insurance?

Yes No

Name of Secondary Medical Insurance Provider

Secondary Medical Insurance ID#

Secondary Medical Insurance Policy or Group ID#

Secondary Medical Insurance Member Date of Birth

Secondary Medical Insurance Member Employer

Relationship to Secondary Medical Insurance Member

Self Spouse Child Other

Exam History

When was the Patient's Last Eye Exam?

Does the Patient Currently Wear Glasses?

Yes No

How Often Does Patient Wear Glasses?

Constantly Reading/Computer Driving Leisure/Fashion Only

Does Patient Currently Wear Contacts?

Yes No

Current Contact Lens Brand

Right Eye Contact Lens Prescription

Right Eye Base Curve (BC)

Left Eye Contact Lens Prescription

Left Eye Base Curve (BC)

Picture of RIGHT contact lens box or blister pack if available

Add file

Please upload a file

Picture of LEFT contact lens box or blister pack if available

Add file

Please upload a file

Reason for Patient's Visit

Primary Care Physician First Name

Primary Care Physician Last Name

Primary Care Physican's Phone Number

Optical and Medical History

Has the patient experienced, or been treated for, any of the following? Check all that apply.

Other Eye Conditions or Disorders

Other Medical Conditions

Medications and Vitals

Current Medications

Please list all medications.

Vitamins

Please indicate all supplements and over-the-counter vitamins.

Medication Drug Allergies

Please include food, tape, latex and dyes.

Is Patient Pregnant or Nursing?

Yes No N/A

Does Patient Smoke?

Yes No Never

How Many Packs Per Day?

1 2 3 4 5+ Social

Does Patient Consume Alcohol?

Yes No

How Many Drinks Per Week?

1 2 3 4 5+ Social

Focused Eye Care

Please fill this form out prior to your scheduled eye exam.

Patient Details

Contact Information

Address

Emergency Contact Information

Demographics

Insurance Verification

Vision Insurance

Medical Insurance

Exam History

Optical and Medical History

Medications and Vitals

Please fill this form out prior to your scheduled eye exam.

Focused Eye Care