Online Patient Forms

Dr Marbun Optometry

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

How did you hear about us?

Billing information

Is The Billing Address Different? Yes

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Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

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Eye History

What is the main reason for your visit today?

Do you currently have any of these symptoms?

Do you currently take any of these eye medications?

Please list any eye surgeries and/or trauma (include dates)

Last Eye Exam

By Doctor

Interested in LASIK?

Hours/day on computer?

Primary Vision Correction

What type of glasses do you wear?

How old are your glasses?

Do you wear contacts?

Contact Lens Wearers Only

OD(Right): Name of lenses

DIAM

SPH

CYL

AXIS

ADD

OS(Left): Name of lenses

DIAM

SPH

CYL

AXIS

ADD

What solution do you use?

Do you have backup glasses?

How often do you sleep in your contacts?

How often do you replace your contacts?

Family Eye History

Does anyone in your family have any of these eye conditions?

Unknown family eye history

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Retinal Dystrophy

Strabismus

Medical History:

Medications No Medications

Drug Allergies No known drug allergies

Vitamins

Over the Counter Medications

Please describe any injuries or surgeries you have had:

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Do you have any of these medical conditions?

Diabetes

Year Diabetes Diagnosed

HbA1c

High Blood Pressure

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Other

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STDs

Policies, Consent, Submit Data

Optomap Retinal Imaging View Optomap Form

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Office Business Policies & Assignment of Insurance Benefits

I understand that exam fees are Non-Refundable. I understand that Prescription Related office visits are included up to 90 days after exam. After 90 days additional fees will apply. Any Non-Prescription Related reasons (eye infection, red eye, etc.) will be charged a different fee regardless of time since exam. I authorize Dr. Riolan Marbun, OD, PC to release and/or request any information required to process my insurance claim(s). I also authorize my insurance benefits to be paid directly to Dr. Riolan Marbun, OD, PC. I understand I am responsible to pay any of the following in advance: deductible, co-insurance, and/or any other balance not paid by my insurance. I understand that if my insurance is not accepted, payment must be made at the time of service. If any services or payments are denied by my insurance, I understand I will be responsible for the full payment of services within 30 days of being notified by the office of Dr. Riolan Marbun, OD, PC.

Initial

Annual Recall Program

I authorize Dr. Riolan Marbun, OD, PC to preschedule my yearly exam and provide my name, address, phone number, email address, and next appointment date(s) and time(s) to Target Optical for the purpose of providing reminder calls, postcards, coupons, and product information, either directly from this office or Target Optical. Reminder calls may be live or prerecorded. I understand that I may revoke this authorization at any time by notifying the office of Dr. Riolan Marbun, OD, PC.

Initial

Privacy Policy (HIPAA)
View HIPAA Notice

I acknowledge that I was provided the opportunity to receive and review a copy of this Privacy Policy Notice, which describes how my health information is used and shared. I understand that the Office has the right to change this Notice at any time. I may obtain a current copy by contacting the Office. I can be assured that my personal health information will not be sold to a third party for such party's own use.

Initial

Patient Signature (or Parent/Guardian):

*This field is required. Typing name will serve as electronic signature

Relation:

Date