Call us: 239-466-2020
schedule an appointment
Request an Appointment
Please provide information in form below and we will contact you to confirm your requested appointment. If you have additional questions, this is an emergency or you would prefer to book by phone call us at 239-466-2020.
Full Name
First
Email
Telephone Number
New Patient?
*
Yes
No
In which office would you like to be seen?
*
Please select an office location
Bonita Springs
Cape Coral
Fort Myers
Lehigh Acres
Naples
Port Charlotte
Punta Gorda
Summerlin
Requested Appointment Date
Date Format: MM slash DD slash YYYY
Referring Doctor (if any)
Message
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.
This iframe contains the logic required to handle Ajax powered Gravity Forms.
pay your bill
Have a code? Click here!
Don’t have a code?
To pay your bill without a code, please call 239-985-7171
A
A
A
Menu
Home
About
Optical
Careers
Doctors
Patients
Patient portal
Patient forms
Patient Information Sheet
Patient Social and Family History
Patient HIPAA Form
Testimonials
Treatments
Cataract surgery
SmartLens®
Laser eye surgery
Glaucoma
Diabetic Retinopathy
Macular degeneration
Droopy eyelid surgery
Cornea related issues
Eye exam
Conditions
Cataracts
Glaucoma
Diabetic retinopathy
Macular degeneration
Vitreous detachment
Chalazion
Blepharitis
Cornea related issues
Droopy eyelids
Dry eye syndrome
Pteryglum and pinguecula
Seminars
Contact Us
Blog
Patient Portal
New Patient Info
Financing Options
Learn About Cataracts
Optical
Patients
Home
»
Patients
»
Patient forms
»
Patient Social and Family History
Patient portal
Patient forms
Patient Information Sheet
Patient Social and Family History
Patient HIPAA Form
Testimonials
Patient Social and Family History
Patient Name
Date of Birth
Pharmacy Name
Pharmacy Phone Number
Please check all that apply
Gender
Male
Female
Preferred Language
English
Spanish
French
German
Other
Race
White
African American
Asian
Black African
American
Mexican American Indian
Other
Ethnicity
Not Hispanic or Latino
Mexican
Latin America
Smoking History
Never
Quit
Currently Smoke
Family History
Check all that apply and explain if related to self or relative
Macular Degeneration
Please select an option
NO
YES
Retinal Detachment
Please select an option
NO
YES
Glaucoma
Please select an option
NO
YES
Diabetes
Please select an option
NO
YES
Ocular History
Have you had Lasik?
Please select an option
NO
YES
Do you wear Contact Lenses?
Please select an option
NO
YES
Have you worn contacts in the past?
Please select an option
NO
YES
Do you have macular degeneration?
Please select an option
NO
YES
Have you had cataract surgery?
Please select an option
NO
YES
Please list any other eye surgeries or eye disease that you have or have had:
REVIEW OF SYSTEMS
Please check each item yes or no as they relate to your health
Eyes
Pain
Please select an option
NO
YES
Double Vision
Please select an option
NO
YES
Floaters
Please select an option
NO
YES
Dry Eyes
Please select an option
NO
YES
Decreased Vision
Please select an option
NO
YES
Excessive Tears
Please select an option
NO
YES
Sandy Feeling
Please select an option
NO
YES
Musculoskeletal
Joint Pain
Please select an option
NO
YES
Stiffness
Please select an option
NO
YES
Arthritis
Please select an option
NO
YES
Ear, Nose, Throat
Hard of Hearing
Please select an option
NO
YES
Ringing in Ears
Please select an option
NO
YES
Vertigo
Please select an option
NO
YES
Gastrointestinal Problems
Stomach
Please select an option
NO
YES
Liver
Please select an option
NO
YES
Blood/Lymph
Easy Bruising
Please select an option
NO
YES
Blood Thinners
Please select an option
NO
YES
Anemia
Please select an option
NO
YES
Kidney/Urinary Problems
Prostate
Please select an option
NO
YES
Bladder
Please select an option
NO
YES
Kidney
Please select an option
NO
YES
Cardiovascular
Chest Pain
Please select an option
NO
YES
HTN
Please select an option
NO
YES
Heart Attack, if yes, when?
Please select an option
NO
YES
Date of Heart Attack
Pacemaker
Please select an option
NO
YES
Dizziness
Please select an option
NO
YES
Neurological
Seizures
Please select an option
NO
YES
Stroke
Please select an option
NO
YES
Alzheimer's
Please select an option
NO
YES
Psychiatric
Anxiety
Please select an option
NO
YES
Depression
Please select an option
NO
YES
Past Medical Surgical History and any illness not listed previously. Please include dates.
Allergies (please list all)
Are any of your medical conditions bothering you today? If so please explain?
Patient Signature
Date
Submit
