Established Patient Health History & Demographics Online Form

Please fill out the information below for the PATIENT who has an appointment with GTOC.  If your appointment is within 2 business days from the current date, please do not submit online forms.  We may not be able to process the information in time for your appointment.  Instead, please print out/fill out the New Patient Info forms and bring them with you on the day of your appointment.  Please plan to arrive 15 minutes early for your appointment and bring your newest insurance cards and photo ID.


If you do not wish to submit your form online you may download, print and fill out your forms and bring them with you to your appointment or fax them to 231-947-8864.


All form submissions are encrypted for transmission.

* required

E-Mail Address *

Date (mm/dd/yyyy) *

Full legal name *

Nickname

Date of birth (mm/dd/yyyy) *

Address (Street address, City, State, Zip. Please include suite numbers and PO boxes)

Social Security Number (xxx-xx-xxxx) THIS FIELD IS OPTIONAL

Parent / Guardian

Family Members / Friends who we can discuss your medical information with. (Example: David Jones, husband)

Preferred Phone Number (xxx) xxx-xxxx

2nd Phone Number (xxx) xxx-xxxx

Do you wear contact lenses?



Local Pharmacy (Name/Street/City)

Mail Order Pharmacy

Eye Medications (Please list all medications with strength of med and dosage instructions, example: Aspirin 325 mg 2 times a day)

Do you take eye specific vitamins? (AREDS, Macular Degeneration)



Do you use artificial tears?



Other Medications (Please list all, Name, Strength, Dosage)

Do you take ASPRIN?

Do you take INSULIN?



Have you ever used Flomax or other prostate medication?



Latex (allergy or sensitivity)?



Allergies (Please list all known allergies or check "None" below)

Past Eye History / Eye Surgery (Please list procedure and year date)

List your Medical Diagnoses

Diabetes Type 1



Diabetes Type 2



High Blood Pressure



Heart Disease



Stroke



Asthma



COPD or Emphysema



Thyroid Disease



Cancer



Type of Cancer

Arthritis



Past Surgeries (Please proceed with year date)

Family History of Eye Diseases (check all that apply)




Primary Care Dr., (Dr. name, Clinic name, City)

Referred by Dr., (Dr. name, Clinic name, City)

Optometrist, (Dr. name, Clinic Name, City)

Other Dr(s) you would like to receive exam info:

Have you ever used smoking tobacco?



Have you ever used smoke-less tobacco (chew/snuff/dipping)?



Do you currently use smoking tobacco?



Do you currently use smoke-less tobacco?



HIPAA Privacy: Please list any family or friends you wish to grant access to your medical records. (optional)

Vision Insurance (Please include: Carrier Name, Contract/ID#, Subscriber Full Name, Subscriber DOB)

Medical Insurance #1 (Please include: Carrier Name, Contract/ID#, Subscriber Full Name, Subscriber DOB)

Medical Insurance #2 (Please include: Carrier Name, Contract/ID#, Subscriber Full Name, Subscriber DOB)

Medical Insurance #3 (Please include: Carrier Name, Contract/ID#, Subscriber Full Name, Subscriber DOB)

Affordable Care Act / Meaningful Use Questions

Race

Language Preference

Ethnicity

To the best of my knowledge the above information is accurate at the time of submission. *



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Traverse City
Local (231) 947-6246
Toll Free: (800) 968-6612

Mon - Wed, 8:00 AM - 5:00 PM
Thurs 8:00 AM - 6:30 PM
Fri 8:00 AM - 4:00 PM

929 Business Park Drive
Traverse City, MI 49686

Petoskey
Local (231) 487-2020
Toll Free: (866) 407-2020

Mon - Fri, 8:00 AM - 5:00 PM

2061 M-119
Petoskey, MI 49770

Sault Ste. Marie
Local (906) 635-9802
Toll Free: (800) 824-2711

Mon - Fri, 8:00 AM - 5:00 PM

511 Ashmun St.
Sault Ste. Marie, MI 49783