Online Patient Form

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Instructions:
  Please fill out these forms as completely as possible. The information collected will be reviewed by the doctors and staff to be used to:
     A. Better understand your unique visual needs
     B. Discover any medical risks to your vision or health
     C. Utilize any vision or medical insurance benefits to your maximum benefit

After completing all information, please submit your data at the bottom of the page. All fields are required with the exception of the contact lens history section of this form. Please choose "none" if options under the medical history or review of systems does not apply to you. If you currently do wear contact lenses, please complete that section of the form. Thank you!

Patient Information

Title Legal- First Last
MI Suffix
Nickname
Address:
Apt/Suite #:
City:
State:
ZipCode:

We have your contact number on file. Please call our office if you need to update or change your contact number.

Email:
Preferred Contact Method:
Guardian/Advocate/ Interpreter:
Relationship to Patient:
Birthdate:
Sex:
Occupation / Grade Level:
Employer / School:
Language:
Ethnicity:
How were you referred?:
Special Considerations (wheelchair, hard of hearing, pregnant, etc.):

Billing Information Is The Billing Address the Same?

Title First Last
MI Suffix
Address

City
State
ZipCode
Home Phone:
Work Phone:

Visual Tasks:

Hours per Day/Frequency
Reading:
Computer Use:
Activities:
Driving:

Eyes Dry or Uncomfortable
Vision Changes Throughout the Day
Red Eyes
Need or Use Drops

Contact Lens History (If Known)



Current Lenses
Brand:
Power: R L
Cyl: R L
Axis: R L
Base Curve: R L

Wear Style: Schedule:
How old are your current contacts?:
Current Solution:

Medical History

Medical, Personal and Family History


Last Eye Doctor:
Last Eye Exam (estimate)
Primary Care Physician:
Last Medical Exam with PCP:
Eye History:

Please List all Eye Surgeries/Injuries/Vision Therapy:
 Other:

Do you experience any of the following symptoms?:
 Other:


If you have multiple choices for the questions below, please choose one, then add a comma and begin typing the rest.

Please list all eye meds you're currently using, including,
over-the-counter & non-prescription drops:
Please list all prescription medications you are currently taking,
including non-prescription supplements:
Vitamins, tobacco, recreational drugs, etc.

Any Medication Allergies?          Family Med History:
Other:
 
 
 
  Other:


Review of Systems

General
Other:
 
Respiratory
Other:
 
Endocrine
Other:
 
Neurological
Other:
Ear, Nose, Throat
Other:
 
Blood/Lymph
Other:
 
Bones/Joints/Muscles
Other:
 
Psychiatric
Other:
 
STD's:
Cardiovascular
Other:
 
Gastrointestinal
Other:
 
Skin
Other:
 
Cancer
Other:
 
Immune
Other:



Eye Health Check

During your exam we will check the health of your eyes either by Optomap retinal imaging or dilating your eyes with eye drops.

Please choose one of the following methods for checking the health of your eyes:

Please read before you submit your online form



Thank you for choosing Coffman Vision Clinic for your eye health needs. At Coffman Vision
Clinic we focus on personal education to prescribe the best treatments, services, and products.
We strive to make a positive difference in our patient's lives as well as our community.

As a courtesy to you, we contact your insurance company to obtain your benefit information.
The insurance company quotes are estimates only and are not a guarantee of payment. Your
co-pay, any deductibles not met, and non-covered services are expected at the time of service.
Any fees not paid by the insurance company are your responsibility.

Thank you for taking the time to complete your online health history form. We ask that you give us at least 24-hour's notice if you need to cancel or reschedule an appointment.

HIPAA and Financial Policy Acknowledgment



Our Notice of Privacy Practices and Financial
Policy can be found on our website: www.coffmanvision.com/privacy-policy/.

**Please click the submit button only ONCE to submit your information**