Premier Eyecare of Edmond -
PATIENT INFORMATION
Name
Address
Date of Birth
Home Phone
Cell Phone
Email
Preferred Contact Method
Call
Text
Email
INSURANCE INFORMATION
Primary Insurance Member's Name
Primary Insurance Member's Date of Birth
MEDICAL HISTORY
Does the patient have any of the following:
Blindness
Cataracts
Glaucoma
Macular Degeneration
Eye Turn or Lazy Eye
Eye Injury or Eye Surgery
Diabetes
High Blood Pressure
Does the Patient have a family member with the following:
Blindness
Cataracts
Glaucoma
Macular Degeneration
Lazy Eye or Eye Turn
Diabetes
High Blood Pressure
Other health conditions
List all medications currently taking
List all known drug allergies
EYEWEAR HISTORY
Has the patient ever had an eye exam?
Date of last exam
Name of previous eye doctor
Were glasses or contact lenses prescribed at that exam?
If yes, when is the correction worn?
What is the patient planning on getting at this visit?
Glasses
Contacts
Unsure
How did you become aware of our office?
Friend recommendation
Insurance provider
Drove by
Other
Before your first visit to our office, you may fill out our new patient form and submit. You may also download the form by clicking on: Medical History Questionnaire to bring with you to our office.  Filling out your paperwork in advance is not a necessity, but may save you time at your visit. 
Website Builder provided by  Vistaprint