Medical History Form for Children

Medical History Form for Children

If you are booking an appointment for an adult, Medical Form For Adults

Medical History Form for Children

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
Parent Name*
First Middle Initial Last
Child Name*
First Middle Initial Last
Child's Preferred Name
Childs Date of Birth*
MM slash DD slash YYYY
Address*
Address Line 2
City*
State*
Zip*
Country*
Childs Gender*
- Female
- Male
Phone, Cell*
Phone, Alternate
Email Address*
Preferred Language*
Race*
Ethnicity*
Communication Preference*
How were you referred to our office?*
Please Specify:
For example, if friend or family, who?

Policy Holders Name*
First Middle Initial Last
Address*
Address Line 2
City*
State*
Zip*
Country*
Cell Phone*
Alternate Phone
Email*
Policy Holders DOB*
MM slash DD slash YYYY
Policy Holders Social Security Number*
(Full social or last 4 digits)
Medical Insurance*
- Yes
- No
Insurance Company Name*
Relationship to Policy Holder*
Subscriber ID #*
Vision Plan*
- Yes
- No
Insurance Company Name*
Relationship to Policy Holder*
Subscriber ID #*