Optometry Patient Intake Form

About this form

The optometry patient intake form is a patient intake document used by optometry practices. New optometry patient intake including vision history, eye health, and insurance. In BoomCloud Forms it is a starting point: every field, heading and statement can be edited before you share it with patients.

Practices may use this template as a starting point and should review the wording against their own professional, regulatory and legal requirements before use.

What's included

This template ships with 12 fields:

• Patient Name — Text
• Date of Birth — Date
• Phone — Text
• Email — Text
• Reason for visit — Text
• Last eye exam — Date
• Do you currently wear glasses? — Single choice
• Do you currently wear contact lenses? — Single choice
• Allergies — Long answer
• Vision insurance provider — Text
• Signature — Signature
• Date — Date

When practices use it

Optometry teams typically attach this form to the new-patient workflow, sending it before the first appointment so the front desk has complete records on arrival. It can be sent digitally ahead of the visit, completed on a tablet in the office, or printed as a PDF.

How to customize it

• Reword any question, add fields, or remove ones your practice doesn't need.
• Apply your practice name, logo and colors so the form matches your brand.
• Switch to another supported language where a translated version exists.
• Share a secure link with the patient, or download a print-ready PDF.