Patient Intake Form | Austin EyeWorks

Patient Information

Patient Name*

First Last

Nickname

Gender*

Date of Birth*

Contact Information

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Email*

Employment

Occupation

Employer Name or School

Emergency Contact

Name*

First Last

Relationship*

Phone*

Referral Source

How did you hear about us?

Insurance
Drive by
Friend / Family
Can't remember / Long term patient

Who can we thank for recommending us?

COVID Information

If you have symptoms consistent with COVID-19 or other infectious disease, please let us know so that we can reschedule your appointment for another day. Masks are now optional in our office for patients. Employees will wear masks when patients wearing masks are in their presence.

Insurance Information

Medical Insurance (Blue Cross, United, etc.)

Company Name

If Other, please list.*

Identification (ID) #

Group Number

Primary Insured (if not the patient):

Name

Relationship

Date of Birth

Vision Plan (VSP, Eyemed, Superior, etc.)

Name of Plan

If other, please list*

ID Number, if applicable

Last 4 Digits of INSURED’s Social Security Number:

Ocular and Medical History

What brings you to the office this visit?*

I need to purchase glasses
I need to purchase contacts
I need to purchase glasses and contacts
I am having a problem with my eyes
Other

Please describe the issue with your eyes

If other, please describe*

Please check any of following that apply to you & add any relevant information

Relevant Information/Other

Medical History

Primary Care Physician

Clinic name

Please check any of following that apply to you & add any relevant information

High blood pressure
Thyroid disease
Diabetes
Autoimmune disease
Are you pregnant or nursing?
Other

Relevant Information/Other

Please list all medications including eye drops you are currently using, (indicate none if not applicable)*

Please list any allergies to medications, (indicate none if not applicable)*

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