Hours

Monday:	8:00 - 5:30
Tuesday:	9:00 - 7:30
Wednesday:	8:00 - 5:30
Thursday:	9:00 - 5:30
Friday	8:00 - 5:30
Saturday:	8:00 - 12:00
Sunday:	Closed

Location

4555 Cemetery Road
Hilliard, Ohio 43026
Click here to view map

Phone: 614-876-4044

Patient Resources

For your convenience, we've provided the following resources. Please call us or email us with any questions you may have:

Welcome - New patient

Welcome Back - Existing patient

Insurance Providers

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ission Statement

It is our goal to give our patients the best of everything!

"COME SEE WHAT YOU'VE BEEN MISSING!"

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WELCOME BACK TO OUR OFFICE

fields marked with an "*" are required

Name

Today's Date

mm/dd/yyyy

Spouse or Parent

Mailing Address

City

State/Province

Zip/Postal Code

Date of Birth

mm/dd/yyyy *

Age

Sex:

Male Female

Home Phone

xxx-xxx-xxxx *

Work Phone

xxx-xxx-xxxx *

Social Security #

xxx-xx-xxxx *

Email Address

(for patient communication only)

MEDICAL HISTORY
Allergies	Arthritis	Heart Disease
Asthma	Cancer	Skin Disorder
Diabetes	Cataracts	High Blood Pressure
Eye Injury	Eye Surgery	Glaucoma
Nerves	Kidney Problems
Other

CURRENT MEDICATIONS (Rx or over the counter)
	Medication Name
Antihistamines
Blood Pressure Pills
Diuretic (water pill)
Oral Contraceptives
Sleeping Tablets
Eye Drops
Others
Allergies to Medications
Date of Last Eye Exam	xx/xx/xxxx
Name of Last Eye Doctor
Date of Last Physical Exam	xx/xx/xxxx
Name of Physician

FAMILY MEDICAL HISTORY
	Relationship to you
Blindness
Glaucoma
Diabetes
High Cholesteral
Other

SOCIAL HISTORY
This information is kept strictly confidential. However, you may discuss this portion with the doctor if you prefer. This information is important for medical purposes as well as compliance with insurance directives.
Would prefer to discuss your Social History information with your doctor?
Yes No
Do you use tobacco products?
YES NO
Do you drink alcohol?
YES NO

Employer (or School)
Occupation (or Grade)
What is the major purpose of this visit?

Any problems with your present contact lenses or glasses?

Vision Benefit	Medicare	EyeMed
	VSP	CVC/UHC
	Flex Plan	UHC
	Other

	How will you settle your account?
Check	Financing	Credit Card	Insurance	Cash

Do you experience........(check those that apply)
Burning	Uncomfortable Glasses
Itchiness	Sudden loss of vision
Nausea	Sensitivity to light
Watery Eyes	Fainting or dizziness
Double Vision	Blurry distance vision
Flashes of Light	Blurry near vision
Glare or Reflection	Gritty feeling in eyes
Soreness	Objects floating in vision
Eye Strain	Trouble seeing at night
Headaches	Dryness
Redness	Other

VISUAL NEEDS
Do You........(check the box if your answer is yes)
Work on a computer for long periods of time?
Have only one pair of glasses?
Want information on thinner, lighter lenses?
Wear bifocals?
Want information on "no line" bifocals?
Prefer not to wear your glasses at times?
Spend a lot of time outdoors?
Ever find a need for prescription sunglasses?
Have problems with glare or reflections (ex: night driving)?
Do work requiring safety glasses?
Participate in sports?	What?
Want more information about corrective vision surgery?
Wear or ever tried wearing contacts?
What kind?

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Specials and Promos

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