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631 Saint Anne St., Suite 103
Rapid City, SD 57701
605.343.4120
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Patient Health

Please fill out the form below and click "submit".

 
Patient Name: * 
Date: * 
What is your main reason for coming for an eye exam?: * 
What is the date of your last exam (N/A if done at Eccarius Eye Clinic)?: * 
When did you last change your glasses, and who prescribed them (N/A if Dr. Eccarius prescribed them)?: * 
List any allergies you have:
List the medications you are currently taking:
Have you ever had any eye injuries, surgeries, or diseases?:
Ophthalmology is a specialized area of medical practice. This information is important for Dr. Eccarius to perform a thorough examination. Thank you for answering the following questions:
Do you have / have you had (please check all that apply):


















































Do you use:
Have you ever:





Has anyone in your family had:


Please list any drug allergies you have:
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