Patient Welcome Form

Welcome to Nora Eye Care. Please take a moment to complete the following information. This form helps to ensure that the information we have is current and accurate. If you have any questions, please do not hesitate to ask.
First Name*
Last Name*
Your Email*
What is your preferred name?
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Social Security Number
Date of Birth*
Month
Day
Year
Cell Phone*
Spouse or Parent(s) Name
Person Responsible for Account
Emergency Contact
Emergency Phone
Height
Weight
Race
How were you referred to our office?

Patient Medical Information Update
Primary Care Physician and Clinic Name
Address of Primary Care Physician
Street Address Address Line 2 City State ZIP Code
Health History
What is the main reason for today's exam?
When was your last eye exam?
When was your last health exam?
Please list your past and current illnesses or injuries (examples: high blood pressure, GERD, Arthritis)
Please list any past surgeries, since your last visit (examples: Cataracts, Lasik, hip, heart, knee)
Please list any current medications including vitamins, and supplements, including dosage amount, how often taken, and how administered (ie: pill, injection)
Current Eye Drops
List any allergies to medications/drugs and the reactions they cause
List any environmental allergies (examples: hayfever, peanuts, pollen)

Secondary Insurance Information