Online Patient Form

Demographics

Patient Information

If you do not have an email or cell phone number please enter NONE.
If no Home Phone, enter your Cell Phone in Both Home and Cell Phone areas.

Title	*First	*Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Nickname	Pronoun
	he/him/his she/her/hers they/them/theirs

*Address:
*City:
*State/ZipCode	WA TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WV WI WY

*Home Phone:
Other Phone:
*Cell Phone:
*Email
*Preferred Contact Method:	Text Message Cell Phone Email Work Phone Home Phone Other Phone
*SSN

The last 4 numbers of your Social Security number is required by many insurance plans to look up your benefits.

*Birthdate (mm/dd/yyyy)
Gender	Male Female
Misc/Guardian

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Billing Information

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Copy Address From Above
Address

City	State	ZipCode
	WA TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WV WI WY

Home Phone:
Work Phone:

Lifestyle - Ocular

*Reason for visit

Vision exam to check glasses prescription Vision exam for glasses and/or contact lenses prescription Medical eye exam for diabetes Medical eye exam for glaucoma Medical eye exam for macular degeneration Medical eye exam for dry eye concerns or disease Medical eye exam for floaters medical eye exam for irritated/itchy/burning eyes Medical eye exam for something in my eye Childrens vision exam recommended by pediatrician Childrens vision exam recommended by school screening Childrens vision exam My primary care doctor recommended an eye exam Other

PRIMARY CONCERN

SECONDARY CONCERN

Review Of Systems

Referring Doctor
Primary Care Doctor
*Last Doctor Visit	< 1 year 2-3 years 4-6 years 7-10 years Over 10 years ago Other

Review Of Health And Medical History

These items are asked due to a Federal requirement.

*Ethnicity	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
*Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Patient Declined to Specify Unknown White

*Preferred Language

English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other

*Gender Identity

Additional gender category (or other) Decline to answer Female-to-Male (FTM)/Transgender Male/Trans Man. Genderqueer, neither exclusively male nor female Identifies as Female Identifies as Male Male-to-Female (MTF)/Transgender Female/Trans women

*Sexual Orientation

Bisexual Choose not to disclose Don't know Lesbian, Gay or homosexual Something else Straight or heterosexual

*Recvd Flu Immun.	Yes No Other
*Recvd Pneumonia Immun.	Yes Other
*COVID Vaccine	Not vaccinated Yes, vaccinated Other

*Allergies	None or NA Itchy eyes Seasonal Environmental Other
*Blood, Lymphatic	None or NA Anemia Leukemia Lymphoma Other
*Cardiovascular	None or NA High cholesterol Congestive heart failure Heart attack Other
*Gastrointestinal	None or NA Reflux/GERD Irritable Bowel Syndrome Ulcerative Colitis Other
*Hypertension?	Yes No Other
*Mental Health	None or NA Bipolar Anxiety Insomnia Other
*Neurological	None or NA Multiple Sclerosis Alzheimer's / Dementia Parkinson's Disease Other
*Respiratory	None or NA Asthma Emphysema COPD Other
*Skin	None or NA Rosacea Acne Eczema / Psoriasis Other
*Urinary	None or NA Erectile Dysfunction Painful urination Urinary difficulties other
*Arthritis	None or NA Rheumatoid Arthritis JRA / JIA Osteoarthritis Other
*Cancer	None or NA Breast Prostate Brain Other
*Ears, Nose, Throat	None or NA Nasal congestion Dry mouth / throat Vertigo/dizzyness Other
*General	No changes Fatigue Weight gain or loss Other
*Diabetes	None Type II Type I Borderline Other
*Migraine/HA's	None or NA Ocular migraines Migraines headaches Tension headaches Other
*Pregnant Or Nursing	No Yes Unsure Other
*Skeletal disease	None or NA Ankylosing Spondylitis Osteoporosis Connective tissue disease Other
*Thyroid, Endo.	None or NA Hypothyroid Myasthenia Gravis Graves disease Other
*Other	None or NA ADHD / ADD Developmental delay Head injury/trauma Other

SURGERY or INJURY	YEAR
None Cancer Surgery Brain Surgery Hip Knee Ankle or foot Hand or wrist Hysterectomy Pituatary Eye Socket Nose Other
None Cancer Surgery Brain Surgery Hip Knee Ankle or foot Hand or wrist Hysterectomy Pituatary Eye Socket Nose Other
None Cancer Surgery Brain Surgery Hip Knee Ankle or foot Hand or wrist Hysterectomy Pituatary Eye Socket Nose Other
None Cancer Surgery Brain Surgery Hip Knee Ankle or foot Hand or wrist Hysterectomy Pituatary Eye Socket Nose Other
None Cancer Surgery Brain Surgery Hip Knee Ankle or foot Hand or wrist Hysterectomy Pituatary Eye Socket Nose Other
None Cancer Surgery Brain Surgery Hip Knee Ankle or foot Hand or wrist Hysterectomy Pituatary Eye Socket Nose Other

Medical And Eye History

Social History and Eye Symptoms

*Smoking Status	Current every day smoker Current some day smoker (not daily) Former smoker (no longer smokes) Heavy smoker (>10 cigs/day) Light smoker (<10 cigs/day) Never smoker (<100 cigs equiv) Smoker (current status unknown) Unknown if ever smoked Other
*Alcohol HX	None Rarely, less than 1/week 2 to 5 drinks/week More than 5 drinks/week More than 1 drink/day Other
*Cannabis HX	None CBD ointment THC Daily THC Weekly THC Monthly Other
*Screen Time	None 0-3 hours/day 3-6 hours/day 6-10 hours/day Over 10 hrs/day Other
*Caffeine HX	None Weekends only Daily 1-2 cups Daily 3-4 cups Daily 5+ cups Other
*Sleep Apnea	None Yes Yes, with CPAP Other
*Headaches	Never 1 Rarely 2 Sometimes 3 Often 4 Always 5 Other
*Neck Pain	Never 1 Rarely 2 Sometimes 3 Often 4 Always 5 Other
*Computer Discomfort	Never 1 Rarely 2 Sometimes 3 Often 4 Always 5 Other
*Eye strain/pain	Never 1 Rarely 2 Sometimes 3 Often 4 Always 5 Other
*Dry or watery eyes	Never 1 Rarely 2 Sometimes 3 Often 4 Always 5 Other
*Light Sensitivity	Never 1 Rarely 2 Sometimes 3 Often 4 Always 5 Other
*Motion Sickness	Never 1 Rarely 2 Sometimes 3 Often 4 Always 5 Other
*Night Blindness	No Poor night vision Horrible night vision Unable to see stars Other

Eye Conditions
*Dry Eye Disease	No Meibomian Gland Disease MGD Ocular Rosacea Sjogen's syndrome Other
*Eyelids	None Stye Crusty eyelids Red eyelids Other
*Lasik or PRK	No LASIK PRK Lens exchange Other
*Glaucoma	No Yes, one eye Yes, both eyes Narrow angles Other
*Cataracts	No Yes Due to injury Due to medication Other
*ARMD	No Yes Dry type Wet type Other
*Retinal Detach.	No After injury After floaters Unknown cause Other
*Crossed Eye	No Right eye Left eye Alternating eye Other
*Blindness	No Retinitis Pigmentosa Macular Degeneration Glaucoma Other
*Other	No Fuch's dystrophy Eyelid cancer Metal in eye Other
*Family Eye History	None or unknown Glaucoma Macular degeneration Blindness Other

Medications

Prescription medications

*Vitamins and supplements

None Aspirin Baby Aspirin 81mg Ibuprofen (Advil) Acetaminophen (Tylenol) Naproxen sodium (Aleve) Multi-vitamins Vit A Vit B Complex Vit B12 Vit C Vit D Vit E biotin Calcium Fe Mg Mn Zn Biotears Fish Oil Flax Evening Primrose oil Borage oil Glucosamine Chondroitin MSM niacin CoQ10 zeaxanthin Lutein iCaps Lutein & Omega 3 Macula Complete Ocuvite / I-caps Preservision AREDS 2 Preservision Ginko-Biloba resveratrol St John's wort Red Rice Yeast Juice+ curcumin garlic green tea extract probiotic Stinging nettle Other

OTC treatments

*Allergies to medications

None Anesthetics-Proparacaine Penicillin Sulfa drugs Enviromental Other

Eye Supplements and Eye Drops

Submit Data / Patient Signatures

Tumwater Eye Center: Office Policy Agreement

WE BILL YOUR INSURANCE: Insurances require Photo ID, Insurance Cards, and Copay due at Each Visit.

    Photo Identification Required at each visit: drivers license, passport, military ID or other.

    Insurance Billing: Current Medical & Vision plan cards required at each visit prior to being examined. We bill primary Medical Insurances for medical eye exams. Secondary insurances are typically not billed. We bill Vision Plans for "routine vision exams" that update vision correction prescriptions. After insurance payments received, any remaining balance are the patient's responsibility.

    Patient Payment Options: Copay and deductible estimates are due at the end of each exam. Debit/credit cards are accepted for payment and are securely tokenized for convenient future visits. We will verify your approval to use the payment method on file to pay for balances on your account. You will be sent an email to obtain access to your patient portal so that you can view and pay invoices. One statement may be mailed at no cost. Each additional statement, if mailed, will incur a $10 fee. Unpaid balances over 60 days will incur additional fees, and will be turned over to a Collection Agency.

WE PROVIDE INNOVATIVE EYE EXAMINATIONS with 100% SATISFACTION GUARANTEE:

    Screening Imaging Fee, $47.00 in 2023: Assessed at every Routine Vision Exam, for all ages. Without eye drops or dilation, we utilize 21st century imaging technology to detect early eye disease. As a screening fee it is not covered by insurance companies and paid by each patient.

    Contact Lenses: Contacts are a medical device that require appropriate fitting, care, and maintenance. Fitting Evaluation Fee: Yearly evaluation is required for all wearers. Fee ranges from $110 to $350. Contact orders conveniently mailed to your address. Year supply orders include free shipping and discounts.

    Glasses & Contact Orders: 100% Satisfaction Guarantee, but all sales are final, thus, no refunds. Frame, lens, and coating warranty is typically two (2) years against manufacturers defects. Accidental damage, attempts to self repair and patient abuse are not covered under warranty. Your custom lens order starts processing immediately, therefore once paid, the order cannot be cancelled.

    Parent or Legal Guardian: One parent or legal guardian must accompany all patients under 18 years old. Our exam rooms are small, thus only one parent or guardian are allowed with patient.

    Verify Glasses Purchased Elsewhere: We take pride in providing quality products. Tumwater Eye Center has no control over accuracy, fit, or quality of glasses purchased elsewhere. Verification of glasses purchased elsewhere, or a recheck of your prescription, will incur additional fees.

WE UTILIZE CURRENT COMMUNICATION METHODS AND TECHNOLOGY:

    Appointment Reminder Authorization: Our communication system is HIPAA compliant and secure. You agree to allow our office to communicate by email, text messaging, and phone calls.

    Missed, Cancelled Within 48 Hrs, or Leave an Appointment Early Fee is $50: Your appointment should last no longer than 90 minutes. Please be patient as we care for your eyes.

    Assignment and Release: I authorize the release of any medical or other information necessary to process claims from Tumwater Eye Center, Inc. to my insurance company. I also authorize payments of insurance benefits to be paid to the provider and/or Tumwater Eye Center, Inc.

By signing below I acknowledge receipt of, and agree to, the above Tumwater Eye Center office policies, and I agree that I am financially responsible for any balance due.

* Patient or Guardian Signature: Date:

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Notice of Privacy Practices

Tumwater Eye Center, Inc.
6510 Capitol Blvd SE Tumwater WA 98501
360.352.6060

View Notice of Privacy Practices Form

The law requires that Tumwater Eye Center, Inc. make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:

I was given the opportunity to read, have read or had explained to me Tumwater Eye Center, Inc.'s Notice of Privacy Practice prior to any services offered.

The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible

I authorize Tumwater Eye Center, Inc. to release my personal health information to the following individuals:

Name:	Relationship To Patient:
Name 2:	Relationship To Patient:
Name 3:	Relationship To Patient:

Please DO NOT release my personal health information to the following, previously added individual:

Name:

Relationship To Patient:

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

* Patient Signature: Date:

If you are signing as a personal representative of the patient, please sign below indicating your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor. Please indicate any other parent, stepparent, guardian or other individual(s) authorized to make medical decisions for the minor.

Representative or Other Authorized Individual Name:	Relationship To Patient:
Representative or Other Authorized Individual Signature:	Date: