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Welcome Back to Eye Rx

Welcome back to Eye Rx. If you are an existing patient, please use the form below to update your information as needed. Keeping your details current helps your doctor provide accurate, efficient care and ensures your visit stays focused on your eye health.

You only need to complete sections that have changed since your last visit, such as medications, medical history, insurance, or contact information.

Thanks for contacting us! We will get in touch with you shortly.

Please complete this new patient paperwork form.

Name *
Today's Date *
Date of Birth *
Sex *
*
Address *
*
*
routine, new glasses, contact lens evaluation, red/painful eye, diabetic exam, medical visit etc.

Medical History

Do you currently have any problems in the following areas? If YES, please provide additional information.

EYES (glaucoma, cataracts, retinal conditions, macular degeneration, corneal conditions etc.) *
ENDOCRINE (diabetes, thyroid etc.) *
EARS, NOSE, THROAT (deafness, stuffy nose, earache, cough, dry mouth etc.) *
GENERAL/CONSTITUTIONAL (fever, heat stroke, weight loss/gain etc.) *
CARDIOVASCULAR (hypertension, cholesterol, stroke, heart attack etc.) *
RESPIRATORY (asthma, wheezing, short of breath etc.) *
GASTROINTESTINAL (IBS, diarrhea, constipation, hernia, ulcers etc.) *
GENITAL, KIDNEY, BLADDER (painful/frequent urination, jaundice, etc.) *
FEMALES - Are you pregnant? Nursing? *
MUSCLES, BONES, JOINTS (joint pain, stiffness, cramps, arthritis, etc.) *
SKIN (eczema, growths, rash, warts etc.) *
NEUROLOGICAL (numbness, headache, seizures, paralysis, etc.) *
PSYCHIATRIC (anxiety, depression, insomnia) *
BLOOD/LYMPH (anemia, leukemia etc.) *
ALLERGIC/IMMUNOLOGIC (seasonal, lupus etc.) *

Family History

(mother, father, grandparent, sibling)

Has any member of your family had these diseases? *
Blindness, Cataract, Glaucoma, Retinal/Corneal diseases, Diabetes, Hypertension, Heart Disease, Stroke, Cancer, Thyroid Disease, Arthritis, Other heritable disease
Do you have allergies to any medications? *
*
Date *
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Need Help or Have Updates to Share? »

If you’re unsure whether an update is required or need assistance completing the form, our team is happy to help. You can contact your Eye Rx location at any time, and we will  make sure your information is up to date before your appointment.

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