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Across the street from CVS Pharmacy

(805) 210-8190
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Home » Patient History Form

Patient History Form

Patient History Form

The following information is required by insurance and allows us to provide you with the best care possible.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • EYE / VISION HISTORY

  • SelfParentBro/SisChildNo
    Arthritis
    Cancer
    Diabetes
    Heart Disease
    High Blood Pressure
    Thyroid Disease
    Skin Disorder
    Asthma
    Allergies
    Eye Disease/Injury
    Eye Surgery
    Lazy Eye
    Cataracts
    Glaucoma
    Macular Degeneration
    Blindness
  • I hereby assign all insurance benefits to Family Optometric Group, and understand I am financially responsible for all charges (whether or not they are covered by insurance) and any service charges (18%).

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Looking to get in your eye exam before the New Year? Few slots are still available! Call or text us to schedule an appointment.