Online Patient Form

Click here to return to the the previous website.

After completing all the forms, please submit your data on the final tab. Thank you!

Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance Plan:
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:

Secondary

Insurance Information
Insurance Name:
Insurance Plan:
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:

Tertiary

Insurance Information
Insurance Name:
Insurance Plan:
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


Social History
Referred By: Referring Doctor:
Family Patients:
Last Eye Doctor: Primary Care Physician:
Last Eye Exam: Location:
Primary Vision Correction:

Do you have:
Sunglasses? Computer glasses? Problems with glare?
Backup Glasses?

Are You Interested in Laser Vision Correction?
Do You Wear Contacts? Type of contacts worn:
Interested In Contact Lenses?
Do you sleep with contacts?
Do you currently use re-wetting drops?

Hobbies:
Medical History
Have you had any eye surgeries?:
Have you had any other surgeries?:

Medication and Seasonal Allergies:
Eye Meds:

Do you take any medications? Please give reason, type and dosage:

How many hours do you spend on the computer/reading?:
Are you constantly going in and out of the sunlight throughout the day?
Are you currently pregnant or nursing?
Family Medical History

Please check what applies to you or your familys health conditions.

                                                       Eye History
   Self   Family   Self   Family
Blindness             Itchy Eyes         
Bloodshot             Lazy Eyes         
Blurred Near             Light Sensitive         
Blurred Distance             Loss of Vision         
Burning Eyes             Poor Night Vision         
Watery Eyes             Halos around Lights         
Double Vision             Temp Loss of Vision         
Dry Eye             Glaucoma         
Eye Infection             Keratoconus         
Eye Surgery             Macular Disease         
Eye Trauma             Cataracts         
Floaters/Spots          
 
 
                                                       Health History
   Self   Family   Self   Family
Cancer             Epilepsy         
Hearing Problems             Migraines         
Vertigo             Headaches         
Heart Disease             Psychological Conditions         
High Blood Pressure             Thyroid Conditions         
Stroke             Diabetes   Type:          
Asthma             Cholesterol         
Emphysema             Hepatitis   Type:          
Gallbladder Disease             Anemia         
Kidney Disease             Fainting Spells         
Arthritis             Learning Disability         
Shingles             Allergies         
Review of Systems
General: Ears, Nose, Throat:
Respiratory: Cardiovascular:
Skin: Genital, Kidney, Bladder:
Psychiatric: Neurological:
Endocrine: Allergic/Immunologic
Blood/Lymph: Muscles, Bones, Joints:

Submit Data


Evaluation of the Health of the Eye

While eye exams generally include a look at the front of the eye to evaluate health and prescription changes, a Optomap Retinal Image of the retina is critical to verify that your eye is healthy. This can lead to early detection of common diseases, such as glaucoma, diabetes, macular degeneration, and even cancer. The exam is quick, painless, and may not require dilation drops.

A Visual Field test is a method of measuring an individuals entire scope of vision, that is their central and peripheral (side) vision. The eye exam will show whether you have a loss of vision anywhere in your visual field. The pattern of vision loss will help your doctor diagnose the cause.

I elect to have Optomap and Visual Field taken today ($45.00)
I elect not to have further Retinal and Visual Field testing

Patient Consent/Financial Responsibility

Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The notice contains a patient rights section describing your rights under the law. You have the right to review our notice before signing this consent. The terms of our notice may change. If we change our notice you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do we shall honor that agreement.

By signing this form you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent in writing signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understand that:

  • Protected health information may be disclosed or used for treatment, payment, or health care operation
  • The practice has a Notice of Privacy Practices and that the patient has the opportunity to review this notice.
  • The practice reserves the right to change the Notice of Privacy Policies.
  • The patient has the right to restrict the uses of their information but the practice does not have to agree to those restrictions.
  • The patient may revoke this consent in writing at any time and all future disclosures will then cease.
  • The practice may condition treatment upon the execution of this consent.

Financial Responsibility

It is our pleasure to help you file your insurance claim forms or take assignment on your vision benefit as designated by the vision plan of which you have indicated you are a member. We provide this service at no additional cost to you and will do all that we can help you receive the maximum benefits allowable under your plan.

In the event the Insurance determines that you are not eligible at the time of service or makes a determination that you are eligible for a reduced level of coverage, by signing this agreement, you do hereby agree to be financially responsible of any and all of the charges incurred by you and paid by the Insurance.


Please check, sign and date that you have read and agree to our policies and then click the SUBMIT button to complete your online forms. Thank you!

I agree to the terms above

Patient Signature:


Date:
After Completing All Forms Submit Data on Final Tab