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Located at the intersection of Lynn Rd and Creedmoor Rd

919-648-0800 Call

919-977-7480 Text

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- Designer Frames
- Eyeglass Lenses
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Hours & Location
Meet Dr. Bassiri
Advanced Services
Eye Care Services
Eye Glasses
- Designer Frames
- Eyeglass Lenses
Contact Lenses
Our Eye Clinic

Home » Patient Info » Online Form » Medical Form

Medical Form

Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

1Patient Information

2Insurance Information

3Medical History

4Ocular History

Today's Date*
MM slash DD slash YYYY
Name*
First Middle Initial Last
Preferred Name
Date of Birth*
MM slash DD slash YYYY
Address*
Address Line 2
City*
State*
Zip*
Country*
Social Security Number*
(last 4 digits)
Gender*
- Female
- Male
Contact Information
Phone, Cell*
Phone, Alternate
Email Address*
Background Information
Preferred Language*
Race*
Ethnicity*
Marital Status*
Employment Status*
Employer
Occupation
Communication Preference*
How were you referred to our office?*
Please Specify:
For example, if friend or family, who?

Date of Last Eye Exam*
- <1 year
- 1-2 years
- 5+ years ago
- 10+ years ago
- Never
Do you wear glasses?*
- Yes
- No
Do you wear contacts?*
- Yes
- No
What Brand?*
How often do you replace your lenses?*
What brand of solution do you use?*
How many hours a day do you wear contacts?*
How many days a week do you wear contacts?*
Ocular Family History
Cataracts*
- Yes
- No
Strabismus/Eye Turn*
- Yes
- No
Glaucoma*
- Yes
- No
Diabetic Retinopathy*
- Yes
- No
Macular Degeneration*
- Yes
- No
Retinal Detachment*
- Yes
- No
Blindness*
- Yes
- No
Other*
- Yes
- No
If other, please specify:
Are you experiencing any of the following?
- Blurry Vision
- Burning
- Distorted Vision/Halos
- Double Vision
- Dryness
- Excess Tearing
- Eye Infection
- Eye Pain
- Floaters
- Headaches
- Itching
- Light Flashes
- Light Sensitivity
- Loss of Vision
- Loss of Side Vision
- Redness
- Sandy, Gritty Feeling
- Sties/Chalazion
- Tired Eyes
- Mucous Discharge
- Other
If other, please specify:
Cancellation Policy*
- A $50 fee is charged to any appointment canceled without a 48 hour notification.
Privacy Policy*
- I have read and agree to the Privacy Policy.
Phone
This field is for validation purposes and should be left unchanged.

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Fusion Eye Care
6400 Creedmoor Rd, #103
Raleigh, NC 27613
Phone: 919-648-0800
https://www.fusioneyecare.com

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