Online Patient Form

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Patient Information


Title*First*LastMISuffixNickname
*Address:
City: State: Zip Code:
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 Different?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Eye History

Primary Reason For Visit: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Last Eye Exam: Last Appointment Type By Doctor:


Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Medical History

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:

Over The Counter Medications:
Other Meds:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot:


Family Medical History



Does anyone in your family have any medical conditions?:

Family Eye History

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

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Blindness:

Social History

Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:

Submit Form / Patient Signatures



Please Click On The Blue Underlined Link Below To View HIPAA Notice Of Privacy Practices.

Notice of Privacy Practices

View Notice of Privacy Practices Form

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    *You may refuse to sign this acknowledgement*

I have received a copy of this office’s Notice of Privacy Practices.

Patient Signature: Date:

Print Name: Date:

*We attempted to obtain acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Signature On File Form

*Responsibility Statement*
Your insurance is a method for you to receive reimbursement for fees you have paid to the optometrist for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages based on your contract with them, not with our office. It is your responsibility to pay in advance for the deductible, coinsurance, or any other balances not paid by your insurance. We will assist you in receiving reimbursement as much as possible, but you are responsible in advance for your bill.

*Financial Responsibility*
By signing this statement you agree to be financially responsible for all charges.

*Authorization to release medical information*
I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine benefits or the benefits payable for related services. This assignment will remain in effect until revoked in writing. A photocopy of this assignment is considered to be as valid as the original.

Patient Signature: Date:

Comprehensive Exam Explanation

In order to provide a comprehensive eye exam the doctors need to examine your retina. We offer two options: A pharmacological Dilation OR Optomap photography. With these types of procedures it allows the doctor to view areas that are not visible behind the eye to finding anything potentially vision threatening or life threatening.

1. The Optomap Imaging is a new technology taking the full peripheral view of the back of the eye; this will not have any side effects. The fee to perform the procedure of the Optomap will be $39.

2. The dilation are specific eye drops that require extra time to dilate the pupil to relax the eye muscle, therefore it can possibly cause you to have blurred vision for up to 6 hours with sensitivity to light. We recommend a driver for this test due to side effects.

Please check ONE of the following:

I would like the Optomap imaging.

I would like to schedule a dilation.

I am refusing medical assessment even though the importance of these health checks have been explained to me.

Reason for refusing:

Print Name: Date:

Signature: