Patient Information Form
1. Text

1. Text

Please fill out the following information before your scheduled exam.  Once received, our office will enter or update your information.  This means less time spent filling out paperwork, and more time spent doing what is important - having your eyes examined!



Patient Information

* field is required

2. Last Name

2. Last Name

*Last Name:
3. First Name

3. First Name

*First Name:
4. Middle Initial

4. Middle Initial

Middle Initial:
5. Address

5. Address

*Address:
6. Address 2

6. Address 2
7. City

7. City

*City:
8. State

8. State

*State:
9. Zip Code

9. Zip Code

*Zip Code: 
10. E-mail

10. E-mail

E-mail Address:
11. Sex

11. Sex

*Sex:
12. DOB

12. DOB

*Date of Birth:
13. SS#

13. SS#

*Social Security Number:
We will only use this to verify insurance benefits
14. Marital Status

14. Marital Status

Marital Status:
15. Employer

15. Employer

Employer:
16. Occupation

16. Occupation

Occupation:
17. PCP

17. PCP

Primary Care Physician:
18. PCP Phone

18. PCP Phone

PCP Phone Number:
19. Diagnosis

19. Diagnosis

Have you been diagnosed with any of the following:
20. Medications

20. Medications

If your are taking any medications, please list them here:
If you are not taking any, enter None

Home  ·  About Dr. Doiron and Staff  ·  Glasses & Contact Lenses  ·  Macular  ·  Post Op  ·  News  ·  Contact Us  ·  Privacy Policy  ·  Site Map  ·  Online Orders  ·  Videos

Copyright © 2017 Richard J. Doiron, OD. All Rights Reserved.

Localized SEO by Crexendo