Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:

City:	State:	Zip Code:

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

How did you hear about us?:

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix

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!

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:

Primary Care Physician:

Last Visit:

Reason:

Pregnant Or Nursing:

Recent Tetanus Shot:

Recent Flu Immunization:

Do you have any of these medical conditions? If yes, please describe:

Diabetes:		Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions? If yes, please describe:

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Eye History

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

Have you had any eye surgeries? Please describe:

Last Eye Exam:

By Doctor:

Primary Vision Correction:

Do you: Have back up glasses?

Want new glasses?

Want backup sunglasses?:

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

Family Eye History

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

Review of Systems

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

Social History

Hobbies:

STD's:

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

Race:

Ethnicity:

Preferred Language:

Privacy Policy & Financial Disclaimer

Pacific Vision Care, Optometric Services, Inc.
5532 Woodruff Avenue
Lakewood, CA 90713
Privacy Policy & Financial Disclaimer

To be compliant with the Federal Health Insurance Portability and Accountability Act of 1996

Please answer and/or check the following questions:

1. Please list the family member or other person, if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment for services, and health care operations):

Name:		Email:		Cell Number:
Address:		City:		State:		ZipCode:

May the above listed person also be used as an emergency contact as well? Yes No

2. I understand that my personal medical file is kept in a secure environment and all information is held in the strictest
confidence. All mailed correspondence is controlled in the same discretionary manner.

3. Please check one:

Yes, I understand and hereby authorize Pacific Vision Care, Optometric Services, Inc. that any and all messages regarding my appointments and completion of my glasses and/or contact lenses can be left on my answering machine or voice mail at home
or work.

No, I do not authorize and agree with the above statement regarding telephone communications. (Please be fully aware that a cell phone is not a secure and private line.)

4. I understand that I am required to pay for all charges on the date of services and/or materials that are rendered, unless I am covered by a vision insurance policy in which the doctors at Pacific Vision Care, Optometric Services, Inc. is a
participating provider and the benefits over the service and material fees.

5. I understand that Pacific Vision Care, Optometric Services, Inc. accepts personal checks, credit cards, or cash. If the bank returns my check as non-payable, I will be charged a $15.00 service fee which will be due and payable within 10 days along with
the amount of the original check.

6. I will pay all insurance co-pays on the date of service. I understand that if I receive a statement in the mail, the amount stating my responsibility is due in 15 days.

7. I understand that I am ultimately responsible for my account in full, even though I have medical or vision insurance. Should there be a problem with my insurance company not paying in a timely manner or for the correct amount, I agree to pay
Pacific Vision Care, Optometric Services, Inc. and settle my differences with my insurance company within the 90 days
from the date of service and the receipt of materials.

I have read, agree and understand this privacy and financial policy.

Signature of Patient: Date:

Online Patient Form

Patient Information

Billing Information

Medical History

Privacy Policy & Financial Disclaimer

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