Complete Your Medical History

Your medical history will need to be completed through our patient portal prior to your visit.


Username & Password:
Your username and password will be first letter of first name capitalized, last name, all lowercase, day born, and last 2 digits of year born.
Example: John Smith both April 5, 1969
Username: Jsmith0559
Password: Jsmith0559

After you log in, a new screen will show tabs on the left side. You may review Contact Information and Insurance but please do not make changes.


Patient Information & History:
Fill out the remaining tabs, printing each section, and clicking save & continue each time.


1.) Pharmacy: Click “Add Surescripts Pharmacy” and add your home pharmacy, If your pharmacy is not listed click “Add Manual Pharmacy.”
2.) Past History & Ocular History: Fill out information under both tabs by checking personally relevant boxes in each section.
3.) Medication: List all medications you are currently taking by typing them into the search bar and selecting them. Fill in all referring blanks such as frequency, date started, etc.
4.) Allergies: If applicable click “Add Allergies.” Search for an select any allergies for you. You will need to describe the reaction, date when the allergy was recorded, and state if the allergy is still active.


You will need to bring each printed section with you to your appointment!




If you can not access the patient portal, you will need to download the history forms here.