please fill out the form completely, or return to home.
Patient Information Form
 
 

 

 

 
 
 

First Name

 Last Name

Middle Initial

 Date of Birth Age  

 

  
  
 

Street Address / PO Box

City

State

ZIP

  

 

 
  
 

Sex

 Marital Status

E-Mail Address

 Home Phone Day Phone  

M

F

   
  
 

First Visit?

Reason for Current Visit

 Last Eye Exam Date   Referred By

Yes

No

 
 
 
  Employment Status Employer Emp. Phone Occupation
 
 
Employer Street Employer City Emp. State Emp. ZIP  
   
  
    Other Contact Information  
 
Person responsible for charges (if not patient) Relationship To Patient Home Phone Work Phone
  
 
Who should we contact in case of an emergency? Relationship To Patient Home Phone Work Phone
 
 
    Eye-Health - Patient     ( check all that apply )  
 
  Amblyopia (Lazy Eye) Eye Surgeries Itchy Feeling
  Blurred Vision - Far Eye Turn Infection of Eye / Lid
  Blurred Vision - Near Floaters / Spots Loss of Vision - Central
  Burning Eyes Fluctuating Vision Loss of Vision - Side
  Cataracts Foreign Body Sensation Mucus / Discharge
  Double / Distorted Vision Glaucoma Redness
  Drooping Eyelid Glare / Light Sensitivity Retinal Detachment
 

Dry Eyes

 Headaches Tearing / Watery Eyes
  
    General-Health - Patient    ( check all that apply )  
 
  Allergies / Hay fever Chronic Cough Kidney Disease
  Asthma / Respiratory Diabetes Psychiatric / Depression
  Blood Disorders Emphysema Rheumatoid Arthritis
  Cancer Gastrointestinal Problems Thyroid / Endocrine Disease
  Cardiovascular / High B.P. Heart Attack / Stroke Skin Disorders
  Chronic Bronchitis Headaches / Migraines Weight Loss / Gain
  
    Family History - Blood Relatives     ( check all that apply )  
 

 

 Amblyopia (Lazy Eye) Color Blindness High Cholesterol
  Arthritis Diabetes Macular Degeneration
  Blindness Eye Turn Retinal Detachment
  Cancer Glaucoma Stroke / Heart Attack
Cataract(s) High Blood Pressure Thyroid Disease
  
 
  Family Physician - Physician's Name

Physician's Phone

Last Medical Exam Date

  

 
  
    Medications - Enter all medications taken by patient ... and for what condition each is taken.  
 
 

Medication

Condition

If Other
1.
2.
3.
4.
5.
6.
7.
8.
 
 
  Enter the name of all medications (or substances) to which the patient is allergic.
 

 
    Please Answer The Following Questions  
 
  Are you pregnant or nursing?

Yes

No

Do you have trouble driving at night?

 Yes No
  
 

  Do you wear glasses?

Yes

No

 Contacts?

Yes No

If Contacts, Type

  

 
  
 
  Do you experience blur, headaches or eyestrain with computer use?

Yes

No

  
  
 

  Are you interested in laser (refractive) surgery to correct your vision?

Yes

No

I have Questions
  
 
 
    Vision Insurance Information    
 

Insurance Company

Primary Insured's Sex

M

F

Patient's Relationship to Insured

:  Self

Spouse

Child

Other

  
Insured's ID # 
 Group #

Insured's Date of Birth
Insured's Name 

Insured's Phone
 
 
 
    Primary Health Insurance Information    
 

Insurance Company 

2nd Insured's Sex

M

F

Patient's Relationship to Insured

»  Self

Spouse

Child

Other

  
Insured's ID # 
 Group #

Insured's Date of Birth
Insured's Name 

Insured's Phone
 
 
 
    Medicare Secondary Health Insurance Information    
 

Insurance Company 

2nd Insured's Sex

M

F

Patient's Relationship to Insured

»  Self

Spouse

Child

Other

  
Insured's ID # 
 Group #

Insured's Date of Birth
Insured's Name 

Insured's Phone
 
    Please enter any comments or additional Information we should know.    
 

 
 
 
 

 
Drs. Kret, Bond, Bond & Miller

Tim Kret, O.D., P.A. , Michael Bond, O.D.
Lindsay Bond, O.D., Matt Miller, O.D.