Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Demographics

General Information
  Title First Last MI Suffix Nickname
Address:
City: State Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Email:
Birthday: (mm-dd-yyyy)
SSN:
Sex: Male Female
Occupation:
Employment Status: Employed Full-Time Student Part-Time Student
Marital Status:
Employer/School Name:
Primary Doctor:
Misc/Guardian:

Billing Information

Is The Billing Address Different?

Vision Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

What is your reason for visiting our office?
What do you currently use most to correct your vision?
How many hours per day do you use a computer?
Are you interested in contact lenses? Are you interested in LASIK?
Are you pregnant?
Do you smoke or use any tobacco products? If yes, how long?
Do you drink any alcohol?
Do you use any recreational drugs?


List all medications, including vitamins and over the counter drugs, you take.
Do you have any allergies or any allergic reactions to medication?
Please list the conditions that YOU have had in the past OR are currently being treated for?

EYES: CONSTITUTIONAL
EAR, NOSE, THROAT VASCULAR / CARDIOVASCULAR
RESPIRATORY GENITOURINARY
MUSCULOSKELETAL SKIN
NEUROLOGICAL PSYCHIATRIC
ENDOCRINE BLOOD/LYMPH
ALLERGIC / IMMUNOLOGIC GASTROINTESTINAL


Family's Medical and Eye History:

Family Medical History


Family Eye History




NORTH TEXAS FAMILY EYE CARE NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

How we may use and disclose your health information: We use health information about you for treatment, to get paid for treatment, for administrative purposes, and to evaluate the quality of care that you receive. For example, your health information may be shared with other providers to whom you are referred. Information may be shared by paper, mail, electronic mail, fax or other methods. We may use or disclose your health information without your authorization for several reasons. If you sign an authorization to disclose information, you can later revoke it to stop any further disclosures

How we may use and disclose your contact information: We use your phone numbers, addresses, and electronic mail addresses in order to contact you regarding your appointments, insurance information, any referrals to doctors for additional testing, contact lens orders and account receivables. We do not sell your personal contact information to third party marketers.

Your rights: In most cases, you have the right to look at or get a copy of your health information that we use to make decisions about you. We limit disclosures to family members, other relatives, caregivers, or close personal friends who may or may not be involved in your care that are listed at the bottom of this form. If they are not listed, you will need to sign an authorization form in order for us to disclose your personal health information to them. If you request copies, we may charge you a cost-based fee. You also have the right to request a list of certain types of disclosures of your information that we have made. If you believe that your health information is incorrect or information is missing, you have the right to request that we correct the existing information or add the missing information.

Our legal duty: We are required by law to protect the privacy of your health information, provide this notice about our privacy practices, follow the privacy practices that are described in this notice, and seek your acknowledgement of receipt of this notice. We may change our privacy policies any time. Before we make a significant change in our policies, we will change our notice. The notice will be prominently displayed in our office. You can also request a copy of our notice at any time. For more information about our privacy policies, contact our privacy officer.

Privacy Complaints: If you are concerned that we have violated your privacy rights, our privacy policies, or if you disagree with a decision we made about access to your health information, you may contact our privacy officer. You may send a written complaint to the US department of Health and Human Services. Our privacy officer can provide you with the appropriate address upon request.

OFFICE POLICY

Our office attempts to verify patient's insurance benefits prior to their appointment. Any copay, deductible, or co-insurance is due at the time of service. We will give you the best estimate possible based off of your benefits quoted. Sometimes benefits are misquoted by your insurance carrier; however we must collect based off their explanation. Once your insurance carrier has finalized your claim, we will make any necessary adjustments to your account. Outstanding balances are due in full upon receipt of statement.

Payment is expected as services are rendered and all services are non- refundable. Should a payment be returned for any reason, including but not limited to, insufficient funds, stopped payment, or closed account, the patient will be liable for the original amount plus any associated NSF fees. Our current NSF fee is $25.00.

There will be no fee for progress visits on glasses or contact lens prescriptions within 90 days of the initial comprehensive exam. After 90 days the usual and customary fees will apply.

Acknowledgement of receipt of Privacy Policy: Please type your name and provide the date below to acknowledge that you have read and received the Notice of privacy practice policy.

Patient Signature: Date:

Legal Guardian signature if patient is a minor:

List of Authorized Persons:

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