Patient Information

Oro Valley Eyecare

520-229-2010 Office
520-229-2111 Fax

Patient Information

Patient Name

Date of Birth

Gender

Male Female

Guarantor Name (if patient is a minor)

Guarantor Date of Birth

Address

City

State

Zip

Phone Number

Number

Cell Home Work

OK to text?

Yes No

Reason For Visit

Medical Insurance Provider

Enter N/A if no insurance

Medical Insurance ID number

Enter N/A if no insurance

Vision Insurance Provider

Vision Insurance ID Number (if applicable)

If you do not have an ID#, many companies use the last 4 digits of your SS#

Name and date of birth of the primary insurance subscriber if different than the patient.

Please upload pictures of the front and back of your insurance cards You can upload multiple photos at once

Add file

Please upload a file

Do you currently wear:

Glasses Only

Contacts Only

Glasses AND Contacts

Neither

If you do not currently wear contact lenses, are you interested in trying them? Please be advised there is an additional charge for a contact lens exam

Yes

What type of contact lenses do you currently wear?

Soft/Disposable Hard/RGP/Gas Permeable

Other

List Other

Medications- Please List All Prescription, OTC, and Supplements- Enter NONE If applicable

Allergies- Enter NONE if applicable

Eye Conditions, Eye Surgeries, Or Eye Trauma- Enter NONE if applicable

Family History

Cancer

Father

Mother

Brother

Sister

Child

N/A

Type 1 Diabetes

Father

Mother

Brother

Sister

Child

N/A

Type 2 Diabetes

Father

Mother

Brother

Sister

Child

N/A

Hypo Thyroid Disfunction

Father

Mother

Brother

Sister

Child

N/A

Hyper Thyroid Disfunction

Father

Mother

Brother

Sister

Child

N/A

High Blood Pressure

Father

Mother

Brother

Sister

Child

N/A

Macular Degeneration

Father

Mother

Brother

Sister

Child

N/A

Glaucoma

Father

Mother

Brother

Sister

Child

N/A

Cataracts

Father

Mother

Brother

Sister

Child

N/A

Other

List Other

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