At Eye Center of Brookings, we offer patient forms online so you can complete them in the convenience of your own home or office.
Name
Mailing Address
Phone Number:
Daytime Phone:
Cell Phone:
Email:
Gender:
Date of Birth:
Last 4 of SNN:
Preferred Language:
Race:
Ethnicity:
Martial Status:
Employer:
Occupation:
How were you referred to our office?
Communication Preference:
Please check off any current conditions you suffer from:
Do you wear glasses?
Do you wear contact lenses?
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Do you drink alcohol?
Do you smoke?
Do you drive?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please refer to our Patient Portal below to submit your forms.Patient Portal
Please bring all insurance cards with you to your appointment.
Insurance Company Name *
Insurance Company Phone Number *
Insured's Name *
Identification Number *
Group Number *
Insured's Date of Birth:
Patient Relation to Insured *
Do you have secondary insurance?
If you have any comments you would like to add, please enter them here *
I have read and agree to the Privacy Policy *
Click here to view the privacy policy
Please use the form below to request an appointment. Our team will connect with you shortly to confirm your appointment. Thank you!
We've copied your review, after you click 'Publish' please paste your review by selecting 'ctrl' + 'v' into the review comments section.
One fine body…
