Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

*This field is required

Apt/Suite #

City

State

Zip Code

Cell Phone

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Home Phone

Preferred Contact Method

Birthday

*This field is required

SSN

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Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Misc/Guardian

Marital Status

How did you hear about our office?

*This field is required

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Vision Insurance

Please bring your insurance card(s) on your visit that we may make a copy to complete your records.

I, the undersigned, certify that I (or my dependent) have insurance coverage with the above insurance and assign directly to Stacie Layne Virden, O.D. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. By signing this statement, I understand that my vision and/or health insurance coverage is a contract between myself and my insurance company. Although Dr. Virden and staff have made every effort to verify my benefits before my appointment, no guarantee can be made that the information received is accurate since incorrect information may be provided by my insurance company from time to time. I understand that it is ultimately my responsibility as the patient to understand my vision and/or health insurance coverage as well as handle any charges my plan does not cover.

***Please check if you agree to the above***

Please enter name (acts as signature)

Notice of Privacy Practices I acknowledge that I have read and understand Notice of Privacy Practices as implemented by Stacie Layne Virden, O.D., P.A and posted at www.wacovision.com. I am aware that I may request a copy of this agreement for my personal records.

Please enter name (acts as signature)

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

If you are not the Primary on the insurance, please check off "Not Primary" below and fill in the Primary account holders information.

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

*This field is required

SSN:

*This field is required

Employer/School:

Primary Medical Insurance

***Please check if you agree to the above***

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

If you are not the Primary on the insurance, please check off "Not Primary" below and fill in the Primary account holders information.

Not Primary On Account: Not Primary

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

*This field is required

SSN:

*This field is required

Employer/School:

Secondary Medical Insurance

***Please check if you agree to the above***

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

If you are not the Primary on the insurance, please check off "Not Primary" below and fill in the Primary account holders information.

Not Primary On Account: Not Primary

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

*This field is required

SSN:

*This field is required

Employer/School:

Please choose from the menu options or select the option to type in your own text. Thank you!

Medical History

Please choose from the menu options

Eye History

The main reason for my exam is:

*This field is required

Which eye?

How long has it been happening?

How bad is it?

Is it changing?

How long does it last?

When do you notice it most?

Does anything make it better?

Is there anything else you want to tell us about it?

Last Eye Exam

*This field is required

Last Eye Doctor

*This field is required

I usually wear:

*This field is required

I need to get new glasses:

I have Back up glasses?

How many hours a day do you spend looking at a screen?

Contact Lens Wearers:

I wear this kind of contact lens:

I wear them this long most days:

I throw them away:

Do you sleep in your contacts? If so, how many days in a row?

Solutions:

Have you ever worn soft contacts?
Yes No

Have you ever worn hard contacts?
Yes No

Brand of Contacts

*This field is required

Comfortability on a scale of 1-10, with 10 being perfect and 1 being terrible:

when I put them in:

when I take them out:

Previous Eye History

Eye Injuries (Foreign objects, Black eye, etc.)
Yes No

Eye Disease (Cataract, Glaucoma, Macular Degeneration, Pterygium, etc.)
Yes No

Eye Surgery (Cataract, Vision correction, etc.)
Yes No

If yes to any of the above, please explain what and when:

Eye Surgeries

Procedure

Eye

Surgeon

Year

Procedure

Eye

Surgeon

Year

Procedure

Eye

Surgeon

Year

Procedure

Eye

Surgeon

Year

Patient Medical History:

Medications No Medications

Drug allergies No known drug allergies

Please Describe any Injuries, Surgeries or Hospitalization you have had

Primary Care Physician

*This field is required

Last Visit

Pregnant or Nursing

Pharmacy of choice

*This field is required

Eye Drops

*This field is required

Family Medical History:

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

*This whole section is required

Disease/Condition	Yes	No	Relationship to You
Blindness
Crossed Eyes
Cataract
Glaucoma
Macular Degeneration
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Thyroid Disease

Review of Systems:

Do you currently, or have you ever had any problems in the following areas:

*This whole section is required

Eyes (Physical)	Yes	No
Eye Pain or Soreness
Fatigue/Tired Eyes
Dryness/ Gritty Feeling
Redness
Burning
Itching
Watering
Eyes (Visual Symptoms)
Light Sensitivity
Halos/Glare
Double Vision
Blurred Vision
Floaters/Flashes
Night Vision Problems
Motion Sickness
Vertigo
Integumentary (Skin)
Rosacea
Metal Allergies
Ears, Nose, Mouth, Throat
Allergies/Hay Fever
Hearing Loss
Respiratory
Asthma
Emphysema
Vascular/Cardivascular
Heart Problems/Disease
Congestive Heart Failure
High Blood Pressure
High Cholesterol
Stroke
Gastrointestinal
Irritable Bowel Syndrome
Crohn's Disease
Endocrine
Thyroid/Other Glands
Diabetes
Lymphatic/Hematologic
Anemia
Bleeding
Autoimmune
Rheumatoid Arthritis
Lupus
Neurological
Headaches/Migraines
Seizures
Dementia
Parkinsons's
Psychiatric

Social History:

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

STD

Race

Ethnicity

Preferred Language

Height:

Feet

Inches

Weight:

Special Needs:

Please select one of the options

Are there any special needs of which we should be aware?

None

Mentally Challenged

Hearing Loss

Autism

ADD/ADHD

Dementia

Dyslexia/Reading Problems

Other: