Eye Rx – Established Patient Update (One-Page, Intake-Style)

Please complete ONLY the items that have changed since your last visit.

PATIENT IDENTIFICATION

Full legal name

First

Last

DOB

Day

Month

Year

Date of visit

Day

Month

Year

CONTACT / DEMOGRAPHICS (if changed)

Address

Street Address

City

State

Zip

Mobile phone

Home phone

Email

Preferred language

Interpreter needed?

Yes

No

RESPONSIBLE PARTY ADDRESS (if different from patient)

Responsible Party Address

Street Address

City

State

Zip

INSURANCE (if changed)

Medical insurance

Medical Member ID

Vision insurance

Vision Member ID

Policy holder name

First

Last

Policy holder DOB

Day

Month

Year

Relationship to patient

PCP / REFERRING PROVIDER (if changed)

Primary care provider

PCP phone

Referring provider

MEDICAL & EYE HISTORY UPDATE (since last visit)

Any new medical diagnoses?

No

Yes

Describe (Medical Diagnoses)

Any new eye problems, injuries, or surgeries?

No

Yes

Describe (Eye History)

MEDICATION & ALLERGY UPDATE

Any new or changed medications?

No

Yes

Details (name / dose / frequency)

Any new or changed allergies or reactions?

No

Yes

Describe (Allergies)

ATTESTATION

I confirm the above reflects all changes since my last visit. If no changes are listed, I confirm my information on file is correct.

Patient / Guardian signature

Date

Day

Month

Year