Online Patient Form
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Demographics
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State/ZipCode
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
WA
WV
WI
WY
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Text Message
Cell Phone
Email
Work Phone
Home Phone
Other Phone
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer / School Name
Misc/Guardian
Drivers License #
Is the Billing Address Different?
Billing Information
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Copy Address From Above
Address
City
State
ZipCode
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
WA
WV
WI
WY
Home Phone:
Work Phone:
Primary
Insurance Information
Insurance Name:
None
Aetna Vision (Aetna Better Health not accepted)
Avesis
Blue Cross Vision (UPMC, CHiP and Medicaid plans not accepted)
BlueCard (Medical visit only)
BlueView Vision
Cigna Vision
Davis Vision/Fashion Focus/Versant (CHiP and Medicaid plans not accepted)
EyeMed (most EyeMed plans accepted)
Geisinger Health Plan
Medicare (Medicare primary only; accepted for exam only)
MetLife (VSP plans accepted only; MetLife through Superior or Davis vision not accepted)
No vision coverage (I will pay out-of-pocket)
NVA (National Vision Administrators) (UPMC, CHiP and Medicaid plans not accepted)
Other vision coverage not listed (I will pay out-of-pocket)
Spectera (Community Care plans not accepted)
VBA (Vision Benefits of America)
VSP (Vision Service Plan) (Gift Certificate plans not accepted)
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:
None
Aetna Vision (Aetna Better Health not accepted)
Avesis
Blue Cross Vision (UPMC, CHiP and Medicaid plans not accepted)
BlueCard (Medical visit only)
BlueView Vision
Cigna Vision
Davis Vision/Fashion Focus/Versant (CHiP and Medicaid plans not accepted)
EyeMed (most EyeMed plans accepted)
Geisinger Health Plan
Medicare (Medicare primary only; accepted for exam only)
MetLife (VSP plans accepted only; MetLife through Superior or Davis vision not accepted)
No vision coverage (I will pay out-of-pocket)
NVA (National Vision Administrators) (UPMC, CHiP and Medicaid plans not accepted)
Other vision coverage not listed (I will pay out-of-pocket)
Spectera (Community Care plans not accepted)
VBA (Vision Benefits of America)
VSP (Vision Service Plan) (Gift Certificate plans not accepted)
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:
None
Aetna Vision (Aetna Better Health not accepted)
Avesis
Blue Cross Vision (UPMC, CHiP and Medicaid plans not accepted)
BlueCard (Medical visit only)
BlueView Vision
Cigna Vision
Davis Vision/Fashion Focus/Versant (CHiP and Medicaid plans not accepted)
EyeMed (most EyeMed plans accepted)
Geisinger Health Plan
Medicare (Medicare primary only; accepted for exam only)
MetLife (VSP plans accepted only; MetLife through Superior or Davis vision not accepted)
No vision coverage (I will pay out-of-pocket)
NVA (National Vision Administrators) (UPMC, CHiP and Medicaid plans not accepted)
Other vision coverage not listed (I will pay out-of-pocket)
Spectera (Community Care plans not accepted)
VBA (Vision Benefits of America)
VSP (Vision Service Plan) (Gift Certificate plans not accepted)
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:
Quaternary
Insurance Information
Insurance Name:
None
Aetna Vision (Aetna Better Health not accepted)
Avesis
Blue Cross Vision (UPMC, CHiP and Medicaid plans not accepted)
BlueCard (Medical visit only)
BlueView Vision
Cigna Vision
Davis Vision/Fashion Focus/Versant (CHiP and Medicaid plans not accepted)
EyeMed (most EyeMed plans accepted)
Geisinger Health Plan
Medicare (Medicare primary only; accepted for exam only)
MetLife (VSP plans accepted only; MetLife through Superior or Davis vision not accepted)
No vision coverage (I will pay out-of-pocket)
NVA (National Vision Administrators) (UPMC, CHiP and Medicaid plans not accepted)
Other vision coverage not listed (I will pay out-of-pocket)
Spectera (Community Care plans not accepted)
VBA (Vision Benefits of America)
VSP (Vision Service Plan) (Gift Certificate plans not accepted)
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
Primary Care Physician:
CONSTITUTIONAL: Fatigue, Weight loss/gain, fever, chills, night sweats
None
Fatigue
Weight loss/gain
Fever
Chills
Night Sweats
Other
OCULAR: Sudden Blurred vision, Dischage, dryness, Flashes/floaters , Loss of vision, pain
None
Sudden Blurred Vision
Discharge
Dryness
Flashes/Floaters
Loss of Vision
Pain
Other
EAR, NOSE, THROAT: Runny Nose, Ear aches, Hearing changes, Vertigo, Sore throat
None
Runny Nose
Earaches
Hearing Changes/loss/ringing
Vertigo
Sore Throat
Other
CARDIOVASCULAR: Chest pain, Palpitations, Swelling of feet, Pain with walking
None
Chest Pain
Palpitations
Swelling of Feet
Pain with Walking
Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
None
Asthma
Bronchitis
Emphysema
COPD
Other
GASTROINTESTINAL: Abdominal pain, Difficulty swallowing, Change in bowel habits
None
Abdominal pain
Difficulty swallowing
Change in bowel habits
Other
MUSCULAR/SKELETAL: Joint pain/stiffness, swelling, reness/warmth, cramps
None
Joint pain/stiffness
Joint swelling
Joint redness/warmth
Cramps
Other
INTEGUMENTARY: Rash, Hair loss, Itching, Pigmented lesions
None
Rash
Hair loss
Itching
Pigmented lesions
Other
NEUROLOGICAL: Muscle weakness, Memory loss, Numbness, Tingling
None
Muscle weakness
Memory loss
Numbness
Tingling
Other
PSYCHIATRIC: Anxiety, Depression, Hallucinations, Nervousness
None
Anxiety
Depression
Hallucinations
Nervousness
Other
ENDOCRINE: Heat/Cold intolerance, Excessive hunger, Excessive Thirst, Excessive urination
None
Heat/cold intolerance
Excessive hunger
Excessive thirst
Excessive urination
Other
ALLERGIC / IMMUNOLOGIC: Swollen Lymph Nodes, Itching/Hives, Hay Fever, Sneezing
None
Swllen lymph nodes
Itching/hives
Hay fever
Sneezing
Other
OTHER SYMPTOMS:
None
Other
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