This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Address Line 2
State / Province / Region*
Zip / Postal Code*
Date of Birth*
Social Security Number (Last 4 digits only!)
How were you referred to our office?
Please check off any current conditions you suffer from*
Do you wear glasses? *
Do you wear contact lenses? *
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Do you drink alcohol?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any conditions your suffer from
Please bring all insurance cards with you to your appointment
Insurance Company Name
Insurance Company Phone Number
State / Province / Region
ZIP / Postal Code
Insured's First Name
Insured's Last Name
Insured's Date of Birth
Patient's Relation to Insured
Do you have secondary insurance?
Do you have a fever or any upper respiratory symptoms (cough, sore throat, runny nose), or have you been diagnosed with pneumonia recently?
Do any of your family members or close contacts suffer from any of these symptoms?
Have you had any contact with someone who has a confirmed case of COVID-19 in the past 14 days?
If you have any comments you would like to add, please enter them here.
Health Information Protection*
All EyeCare Services
At Professional Eye Care at Westar , we provide the highest quality eye care to all our patients. Schedule your appointment today.
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