Patient Intake | Citrus Heights Optometry

Patient’s Name (please print)

Birth Date

M or F

Have you been seen at this location before?

Yes

No

Personal Medical Information: Do you have problems with any of these systems? If yes, please check the box.

Any allergic reactions to medications or other substances?

Yes

No

If yes, please list:

Please check Yes or No

Do you smoke?

Yes

No

If Yes, How Much?

Do you drink alcohol?

Yes

No

If Yes, How Much?

Do you take medications?

Yes

No

If yes, please list names & how often:

Do you use other substances?

Yes

No

Any eye problems at this time? Please explain:

Please sign below that you have reviewed all information above and it is correct to the best of your knowledge.

Professional fees, such as exam and contact lens fitting fees, represent payment for services that were rendered (even if not successful)

and are not refundable.

Signature

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Patient Intake Form