The Christian Eye Clinic, PLC

EyeCare With A Vision For Life!

 
 
Patient's Demographics
 
 To Speed Your Visit, Please Fill & Submit Online If. 
 
 ? You are New to The Christian Eye Clinic.

 ? It has been more than Three Years since your last Exam.

 ? There is a Change in your Demographics or Health Conditions.

 
 A Separate Form is Needed For Each Patient.
 

Demographics Form

Title:
Last Name: *
First Name: *
Middle Name:
Suffix:
Address: *
Address 2:
City: *
State: *
Zip Code: *
Home Phone: *
Work Phone:
Cell Phone:
Fax, if any
Email: *
Gender: *
Date of Birth (MM/DD/YYYY): *
SSN:
Marital Status: *
Employment Status: *
Employer/School:
Occupation:
How did you hear about us?
Guardian, if a minor:
Relation to Patient:

Insurance Info

Do You Have Vision Ins?*

Vision Ins. Carrier:*
Policy ID #:*
Group #:*
Policy Holder:*
Policy Holder Name:*
Policy Holder DOB (MM/DD/YYYY):*

Health Ins.

Health Ins. Carrier:
Policy ID #:
Group #:
Policy Holder:
Policy Holder Name:
Policy Holder DOB (MM/DD/YYYY):

Healthcare Information

Primary Care Physician:
Your Pharmacy:
Do you take any medication? *
Do you have any drug allergies? *
Do you have any systemic disease or surgery? *
Do you have any eye disease or surgery? *
Do you have any family history of systemic or eye disease? *
Smoking: *
Drinking: *
I acknowledge that: *
HIPAA Privacy *
I acknowledge that: *

 
The Christian Eye Clinic  7011 Douglas Ave.  Urbandale, IA  50322-3223 Tel (515) 333-3333  Fax (515) 283-2020  All Rights Reserved.