Patient Form

Name: Village Visions
Address: 3986 Jordan Rd, Skaneateles, NY, 13152, US
Telephone: 315-685-2020
Price range: $000 - $300

Complete and submit this form before your appointment.
Basic Information
To 'Submit' form, all required fields in this section must be filled out.
Name*
First Middle Last
Sex*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Marital Status*
SSN Last 4*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Employment Status
Occupation
Allow Messaging
- Hone
- Text
- Email
Home Phone
Cell Phone
Email Address
Employer Info
Employer Name
Occupation
Spouse/ Partner's name
First Last
Date of Birth
MM slash DD slash YYYY
Employer
Occupation
Other Contact Info
Person responsible for charges
Relationship to Patient
Phone
Emergency contact
Emergency contact relationship
Phone
Visit Information
First Visit
- Yes
- No
Last eye exam date
MM slash DD slash YYYY
Reason for current visit
Referred by
Last Medical exam date
MM slash DD slash YYYY
Doctor's Name
Eye Health - Check all that apply
- Amblyopia
- Burning Eyes
- Drooping Eyelid
- Eye Turn
- Foreign Body Sensation
- Headaches
- Loss of Vision - Central
- Redness
- Blurred Vision - Far
- Cataracts
- Dry Eyes
- Floaters/Spots
- Glaucoma
- Itchy Feeling
- Loss of Vision - Side
- Retinal Detachment
- Blurred Vision - Near
- Double/Distorted Vision
- Eye Surgeries
- Fluctuating Vision
- Glare/Light Sensitivity
- Infection of eye/lid
- Mucus/Discharge
- Tearing/Watery Eyes
General Health - Check all that apply
- Allergies/Hay Fever
- Cancer
- Chronic Cough
- Gastrointestinal Problems
- Kidney Disease
- Thyroid/Endocrine Disease
- Asthma/Respiratory
- Cardiovascular/High BP
- Diabetes
- Heart Attack/Strokes
- Psychiatric Depression
- Skin Disorders
- Blood Disorders
- Chronic Bronchitis
- Emphysema
- Headaches/Migraines
- Rheumatoid Arthritis
- Weight Loss/Gain
Do you smoke tobacco products?
- Yes, I smoke everyday
- Yes, I smoke occasionally
- No, I'm a former smoker
- No, I've never been a smoker
Do you drink alcohol?
- Yes
- No
Family history - Blood Relatives
check all that apply
CONDITION
Blindness
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Glaucoma
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Crossed Eyes
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Eye Surgeries
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Macular Degeneration
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Retinal Detachment
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Thyroid Disease
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Lupus
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Kidney Disease
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
High Blood Pressure
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Arthritis
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Cancer
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Diabetes
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Heart Disease
- MOTHER
- FATHER
- SISTER/BROTHER
- GRANDPARENTS
Medications
Enter all medications taken, and for which condition each is taken. For each medication beyond the first, please click the plus symbol and enter your information.
Medication Condition
Allergies
Enter all medications or substances to which the patient is allergic
Please answer the following questions
Are you pregnant or nursing?
- Yes
- No
Do you drive?
- Yes
- No
Do you have trouble driving at night?
- Yes
- No
Do you wear glasses?
- Yes
- No
Do you wear contacts?
- Yes
- No
Do you experience blur, headaches, or eyestrain with computer use?
- Yes
- No
Are you interested in laser (refractive) surgery to correct your vision?
- Yes
- No
Have you ever been exposed to or infected with -
- Hepatitis
- HIV
- Syphilis
VISION Insurance Information
Insurance Company
ID Number
Patient's relationship to Policy Holder
- Self
- Spouse
- Child
Policy Holder's Sex
- Male
- Female
Name of the Policy Holder
Policy Holder's Phone Number
Policy Holder's Date Of Birth
MM slash DD slash YYYY
MAJOR MEDICAL Insurance Information
Insurance Company
ID Number
Patient's relationship to Policy Holder
- Self
- Spouse
- Child
Primary Policy Holder's Sex
- Male
- Female
Name of the Policy Holder
Policy Holder's Phone Number
Policy Holder's Date Of Birth
MM slash DD slash YYYY
Additional Comments
Is there anything else we should know? Let us know below.

Medication	Condition

Basic Information

Employer Info

Other Contact Info

Visit Information

Family history - Blood Relatives

Medications

VISION Insurance Information

MAJOR MEDICAL Insurance Information

Village Visions