First Name [ REQUIRED ] Last Name [ REQUIRED ] Birthdate Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Home Phone Cell Phone e-mail Job Title or Grade Employer or School Hobbies How did you hear about us? Insurance Family Friend Phonebook Google Twitter Yelp Facebook Golf Ad Loveland Map Vision Screening Other
Primary Holder DOB of Primary SSN or ID# of Primary Relationship to Patient Insurance Company Group ID
What is the reason for your visit?
Blurry Vision Headaches Double Vision New Floaters Recent Flashes of Light Light Sensitivity
Cataracts Macular Degeneration Glaucoma Diabetic Retinopathy Dry Eyes
Lazy Eye Diabetes Depression High Blood Pressure Arthritis
Heart Disease Thyroid Disease Lung Disease High Cholesterol Pregnant
Cancer Stroke Use Tobacco Drink Alcohol Use Illicit Drugs
General Medications
Eye Medications
Medication Allergies
Blindness Crossed Eyes Glaucoma Macular Degeneration
Retinal Detachment Arthritis Cancer
Diabetes Heart Disease High Blood Pressure
Kidney Disease Lupus Thyroid Disease