Online Patient Form

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Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:
City:		State/ZipCode

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer / School Name
Misc/Guardian

Is the Billing Address Different?

Billing Information Address Same As Above

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

Primary Medical Insurance

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 Medical Insurance

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

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

Reason for Visit:	Secondary Reasons:

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Please describe any injuries or surgeries you have had:

Height: ft. in. Weight: lbs.

Primary Care Physician:

Last Visit:

Reason:

Other Specialist:		Reason seen by specialist:
Other Specialist:		Reason seen by specialist:

Pregnant Or Nursing:

Recent Tetanus Shot:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:

Last Eye Exam:

By Doctor:

Primary Vision Correction:

Do you: Have back up glasses?

Want new glasses?

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

Days per week worn:

Hours per day worn:

Review of Systems -

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

Social History

Hobbies:

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

Race:

Ethnicity:

Preferred Language:

STD's:

Family Medical History -

Unknown family history

Diabetes:

Type:

Year Diagnosed:

HbA1C:

High Blood Pressure:		Describe:
High Cholesterol:		Describe:
Thyroid Disease:		Describe:
Heart Problems:		Describe:
Cancer:		Describe:

Family Eye History -

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

Insurance Authorization

I request that payment of authorized insurance benefits for any services furnished to me, be made on my behalf to Amador Valley Optometric.

I authorize any holder of medical information about me to release to my insurance company and its agents any information needed to determine these benefits or the benefits payable for related services. I understand that I am responsible for the charges not paid by the insurance plan. I further understand that accounts greater than 60 days in arrears accrue a $5.00 monthly service fee and may also be sent to collections.

I understand that I am responsible for the charges not paid by the insurance plan.

Signature: Date:

Notice of Privacy Practices

**Click here to view our Notice of Privacy Practices**

Acknowledgement

I have received a copy of the Amador Valley Optometric Notice of Privacy Practices.

Signature: Date:

If signing as a parent or guardian, please provide the following:

Patient Name: Is patient a minor?: Yes No Relation: