Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Master Miss

Address:
City:		State/ZipCode	CA AL AK AZ AR 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 TX UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
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 #

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Billing Information

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

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Address

City	State	ZipCode
	CA AL AK AZ AR 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 TX UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary Medical

Insurance Information

Insurance Name:	None New Insurance New Insurance AARP AARP Medicare Complete by Secure Horizons AARP Medicare Complete through United Healthcare AARP Medicare Supplement/Fixed Indemnity by UHC Advantra Freedom-A Coventry Health Care Plan Aetna Coventry MC AETNA Health Medicare Plans Aetna Medical Anthem Blue Assurant Healthcare Bankers Life BLUE CROSS BLUE SHIELD CAPITAL BLUE CROSS Care First BCBS CBC blue journey MC CBC Medicare CIGNA Co-Managements COLLECTIONS Combined Insurance CORE SOURCE Coventry Health Care National Network CSI DAVIS VISION DMERC Reg. A Everence GEHA HIGHMARK BLUE SHIELD Highmark Freedom Medicare Plan HMO Highmark Medicare Plan HRF/PPO Highmark Medicare plan HSR HOP Humana Independence BCBS MEDICARE New Era OSCOP OTHER Pennsylvania National Mutual Casualty Insurance Company Railroad Medicare ROYAL NEIGHBORS OF AMERICA Sterling Investors Life Insurance TEAMSTERS Thrivent Financial Trans America Life Insurance Company United Healthcare United World Life Insurance Company UPMC Health Plan VBA Vibra Health MC VSP Wellspan
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 Information

Insurance Name:	None New Insurance New Insurance AARP AARP Medicare Complete by Secure Horizons AARP Medicare Complete through United Healthcare AARP Medicare Supplement/Fixed Indemnity by UHC Advantra Freedom-A Coventry Health Care Plan Aetna Coventry MC AETNA Health Medicare Plans Aetna Medical Anthem Blue Assurant Healthcare Bankers Life BLUE CROSS BLUE SHIELD CAPITAL BLUE CROSS Care First BCBS CBC blue journey MC CBC Medicare CIGNA Co-Managements COLLECTIONS Combined Insurance CORE SOURCE Coventry Health Care National Network CSI DAVIS VISION DMERC Reg. A Everence GEHA HIGHMARK BLUE SHIELD Highmark Freedom Medicare Plan HMO Highmark Medicare Plan HRF/PPO Highmark Medicare plan HSR HOP Humana Independence BCBS MEDICARE New Era OSCOP OTHER Pennsylvania National Mutual Casualty Insurance Company Railroad Medicare ROYAL NEIGHBORS OF AMERICA Sterling Investors Life Insurance TEAMSTERS Thrivent Financial Trans America Life Insurance Company United Healthcare United World Life Insurance Company UPMC Health Plan VBA Vibra Health MC VSP Wellspan
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:

Primary Vision

Insurance Information

Insurance Name:	None New Insurance New Insurance AARP AARP Medicare Complete by Secure Horizons AARP Medicare Complete through United Healthcare AARP Medicare Supplement/Fixed Indemnity by UHC Advantra Freedom-A Coventry Health Care Plan Aetna Coventry MC AETNA Health Medicare Plans Aetna Medical Anthem Blue Assurant Healthcare Bankers Life BLUE CROSS BLUE SHIELD CAPITAL BLUE CROSS Care First BCBS CBC blue journey MC CBC Medicare CIGNA Co-Managements COLLECTIONS Combined Insurance CORE SOURCE Coventry Health Care National Network CSI DAVIS VISION DMERC Reg. A Everence GEHA HIGHMARK BLUE SHIELD Highmark Freedom Medicare Plan HMO Highmark Medicare Plan HRF/PPO Highmark Medicare plan HSR HOP Humana Independence BCBS MEDICARE New Era OSCOP OTHER Pennsylvania National Mutual Casualty Insurance Company Railroad Medicare ROYAL NEIGHBORS OF AMERICA Sterling Investors Life Insurance TEAMSTERS Thrivent Financial Trans America Life Insurance Company United Healthcare United World Life Insurance Company UPMC Health Plan VBA Vibra Health MC VSP Wellspan
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 Vision

Insurance Information

Insurance Name:	None New Insurance New Insurance AARP AARP Medicare Complete by Secure Horizons AARP Medicare Complete through United Healthcare AARP Medicare Supplement/Fixed Indemnity by UHC Advantra Freedom-A Coventry Health Care Plan Aetna Coventry MC AETNA Health Medicare Plans Aetna Medical Anthem Blue Assurant Healthcare Bankers Life BLUE CROSS BLUE SHIELD CAPITAL BLUE CROSS Care First BCBS CBC blue journey MC CBC Medicare CIGNA Co-Managements COLLECTIONS Combined Insurance CORE SOURCE Coventry Health Care National Network CSI DAVIS VISION DMERC Reg. A Everence GEHA HIGHMARK BLUE SHIELD Highmark Freedom Medicare Plan HMO Highmark Medicare Plan HRF/PPO Highmark Medicare plan HSR HOP Humana Independence BCBS MEDICARE New Era OSCOP OTHER Pennsylvania National Mutual Casualty Insurance Company Railroad Medicare ROYAL NEIGHBORS OF AMERICA Sterling Investors Life Insurance TEAMSTERS Thrivent Financial Trans America Life Insurance Company United Healthcare United World Life Insurance Company UPMC Health Plan VBA Vibra Health MC VSP Wellspan
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:

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

Medical History

Chief Complaint

LEE

PCP

Family Medical History Unknown family history

Condition	Patient	Mother	Father	Sibling	No	Describe
Diabetes
Hypertension
Thyroid
Vascular Disease
Cancer

Pregnant/Nursing

No Unsure Pregnant Nursing Other

Last Physical Exam

Review Of Systems

Major Injury/Surgery	None --Abdominal-- appendectomy cholecystectomy gastric by-pass hernia repair lap band --ENT-- adenoidectomy sinus surgery tonsillectomy tympanostomy --Ortho-- broken ankle broken leg broken wrist carpal tunnel herniated discs hip replacement knee sx knee replacement shoulder sx --ObGyn-- C-section DandC hysterectomy lumpectomy mastectomy ovariectomy tubal ligation --Neuro-- brain aneurism brain hem brain tumor concussion spinal cord injury TBI --Thoracic-- abdominal aneurism aortic aneurism coronary bypass coronary stent hiatal hernia heart valve repair heart valve replacement pacemaker pacemaker/defribrillator --Urology-- prostatectomy vasectomy Other
Other MHx	None acid reflux acne rosacea Alzheimer's dz ankylosing spondylitis anxiety asthma atherosclerosis atrial fib autism benign prostatic hyperplasia bipolar carpal tunnel syndrome Celiac dz chronic fatigue cluster headaces congestive heart failure COPD Crohn's dz dementia depression diverticulitis Down syndrome eczema emphysema endometriosis epilepsy erectile dysfunction fibromayalgia gallstones GERD gonorrhea gout heart attack hepatitis herpes simplex HIV/AIDS hypercholesterolemia hyperlipidemia hypertriglyceridemia IBS insomnia kidney dz kidney stones migraine multiple sclerosis myasthenia gravis osteoarthritis Parkinson'd dz polycystic ovary syndrome psoriasis rheumatoid arthritis sarcoidosis schizophrenia shingles sinusitis sleep apnea systemic lupus (SLE) TB temporal arteritis vertigo Other
General	good fever fatigue loss of appetite weight gain weight loss Other
ENT	None chronic cough congestion daytime drowsiness dry mouth/throat gasp while sleeping headache hearing problems heavy snoring morning headaches runny nose sinus problems sleep apnea tinnitus toothache hypercholesterolemia Other
CVD	None chest pain hypertension cholesterol racing heartbeat shortness of breath swollen feet/ankles TIAs Other
Respiratory	None asthma chronic cough cyanosis productive cough shortness of breath wheezing Other
Gen/Ur	None overactive bladder painful urination underactive bladder urgency in urination urinary incontinence Other
GI	None abdominal pain bloody stools constipation dark urine diarrhea gastric reflux (GERD) jaundice nausea vomiting Other
Endoc	None addison's disease adrenal gland disorder connective tissue disease cushing's disease gigantism graves disease growth hormone disease hashimoto thyroiditis lupus marfan syndrome myocarditis pituitary disease polycystic ovary syndrome polyendocrine syndrome polymyositis rheumatoid arthritis sjogren syndrome ---Hyperthyroid--- heat intolerance sweaty diarrhea mood swings palpitations weight loss decreased menstruation ---Hypothyroid--- cold intolerant fatigue depression hair loss heavy periods constipation dry skin ---Diabetes--- frequent urination thirst hunger dizziness sweating headache ---Adrenal--- chronic hypotension darkening of skin ---Reproductive--- menstrual changes changes in libido ED Other
Muscles, Bones, Joints	None arthritis decreased range of motion gout joint pain muscle cramps pain/tenderness rheumatoid arthritis stiffness swelling weakness Other
Skin	None acne blisters cysts dandruff eczema erythema growths nodules psoriasis rash rosacea scales seborrheic / actinic keratosis ulcerations warts Other
Neurological	None alzheimer balance problems changes in senses dementia headaches memory problems muscle weakness numbness/tingling personality changes poor balance schizophrenia speech problems tremors vertigo Other
Psych	None anxiety changes in eating habits changes in sex drive delusions depression excess anger excessive worrying frequent mood changes hallucinations insomnia obsessive/compulsive paranoia social withdrawal substance abuse suicidal violence Other
Blood/Lymph	None aids anemia arthritis auto-immune disease hodgkin lymphoma lupus lymphoma rhematoid arthritis bleeding gums cuts slow to clot easy bruising heavy periods hx of significant blood loss jaundice nosebleeds pale skin pounding in ears rapid hearbeat shortness of breath Other
Allergy/Immune	None asthma hiv hives itching mild allergy symptoms severe allergy symptoms redness running nose or eyes sneezing swelling swollen lymph nodes Other

Condition	Patient	Mother	Father	Sibling	No	Describe
Glaucoma
Macular Degeneration
Retinal Detachment
Cataract
Amblyopia/Strabismus

Ocular Injury/Surgery/Lazer	None Anti-VEGF tx blepharoplasty corneal transplant cryo ECCE/IOL filtering procedure focal laser grid laser laser trabeculoplasty LASIK LPI peripheral retinal laser PRK PRK PRP ptosis repair RD repair RK scleral buckle SLT strab sx stromal puncture valve YAG cap Other
Other History	None choroidal nevus episcleritis chalazia frequent styes corneal ulcers GPC keratoconus Fuch's endothelial dystrophy uveitis Other
Rx/Over The Counter Drops	None Art Tears Oasis Tears Refresh Systane Blink Visine Restasis Xiidra Other

Medical Insurance
Vision Plan
Marital Status	Annulled Divorced Domestic Partner Interlocutory Legally Separated Married Never Married Polygamous Widowed Other
Referred By
Occupation/Grade
Employer/School
Parent/Guardian
LiveAlone	assisted living No nursing home Yes Other
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	None social occasional 1-2 drinks/day several drinks/day Other
Meds Sum No current medications	None Accupril / Quinapril Aciphex / rabeprazole Actonel / risedronate Actos Acyclovir Adderall Advair Diskus Albuterol Allegra / fexofenadine alprazolam Altace / ramipril Amaryl / glimepiride Ambien / zolpidem Amiodarone amlodipine amoxicillin Aricept / donepezil Arimidex / Anastrozole Atacand / candesartan atenolol Augmentin Avandia / rosiglitazone Avapro / irbesartan azithromycin BCP Buspar Captopril Carbamazepine Casodex / bicalutamide Celebrex Celexa / celecoxib Cialis Cipro / ciprofloxacin citalopram Clarinex / desloratadine Clonidin Combivent / albuterol-ipratropium Coreg / carvedilol Coumadin / warfarin Cozaar / losartan Crestor Depakote Detrol / tolterodine Diclofenac Dilantin Diovan / valsartan Ditropan XL / oxybutynin Effexor / venlafaxine Evista / raloxifene Exelon / rivastigmine Flomax / tamsulosin Flonase / fluticasone Flovent / fluticasone Fosamax / alendronate furosemide gabapentin Glucophage / metformin Glucotrol / Glipizide Glyburide HCTZ Humulin / insulin hydrocodone-acetaminophen Hydrocortisone Hyzaar losartan Lanoxin / digoxin Lantus / insulin Lasix Lescol / fluvastatin Levaquin / levofloxacin levothyroxine Levoxyl Lexapro / escitalopram Lipitor / atorvastatin lisinopril Lotensin / benazepril Lotril / amlodipine-benazepril metformin Methlyprednisolone metoprolol Mobic / meloxicam Monpril / fosinopril Nasacort Nasonex / mometasone Neurontin / gabapentin Nexium / esomeprazole Norvasc / amlodipine Novalog omeprazole Oxycodone Oxycontin / oxycodone Paxil / paroxetine Pepcid Plaquenil Plavix / clopidogrel Pletal / cilostazol Pravachol / pravastatin Prednisone Premarin / estrogen Prempro Prevacid / lansoprazole Prilosec / omeprazole Procar / finasteride Protonix / pantoprazole Proventil Prozac Risperdal / risperidone Ritalin Seroquel / quetiapine sertraline simvastatin Singulair / montelukast Synthroid / levothyroxine Tetracycline Topamax Toprol / metoprolol Tricor / fenofibrate Ultracet / tramadol-acetominophen Valium Viagra / sildenafil warfarin Wellbutrin / bupropion Xanax Zantac Zestril Zetia / ezetimibe Zithromax / azithromycin Zocor / simvastatin Zoloft / sertraline zolpidem Zyrtec Other
Allergy Sum No known drug allergies
Vit/Supp	None 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 Yeast Rice Juice+ curcumin garlic green tea extract probiotic Stinging nettle Other
Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Patient Declined to Specify White Other
Ethnicity	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
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

Submit Data / Patient Signatures

Acknowledgment of Privacy Policy and Practices

I understand that in an attempt to protect the privacy of my identifiable health information, Fredericksburg Family Eye Care has established a Privacy Policy and guidelines for Privacy Practices within their office. This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purposes of diagnosis, treatment, payment and health operations. In accordance with HIPAA Regulations, a copy of the Fredericksburg Family EyeCare Privacy Policy and Practices has been made available to me while in the office today. Should I choose to have a personal copy, one will be given to me at no charge.

I have read, understand and acknowledge the Privacy Policy and Practices of Fredericksburg Family EyeCare

Signature: Date:

Release of Information:

I authorize release of my information and/or verbal contact with the following person(s) in regards to my care, scheduling, and messages.

Name: Relationship To Patient:
Phone:

Name: Relationship To Patient:
Phone:

Patient Payment Policy

Payments at time of services by cash, check, Visa/MasterCard/Discover are expected. Insurance patients are expected to pay their co pays on day of service. IF any charges are returned by insurance at a later date a monthly statement will be sent to you for collection. We do accept several insurance plans. We request that you bring along all appropriate information. We understand there are occasions for a delay with payments. However, we send statement reminders monthly and expect all patients to clear up any billing or insurance balances within 60 days of the date of service.

A monthly 1.5% interest fee will be charged on any account retaining a balance more than 60 days from the date of service/receipt of goods. If an account balance is over 90 days and we are forced to send the account to collections then you as the patient/customer will also be responsible for any new charges being incurred by the Doctor for hiring these services and you may also be removed from our future patient list. A charge of $25.00 will be added for any returned check. I request that payment of my insurance benefits be made to me or on my behalf to Dr. Monika Groff for any services rendered. I authorize any holder of medical information about me to release to the health care financing administration and its agents any information needed to determine these benefits payable for related services.

Frames and Lenses are nonrefundable due to the custom nature of manufacturing. You have 30 days to request changes due to non-adjustment to prescription. We are not responsible for breakage of frames and lenses not purchased here or older than 1 year from purchase. All frames have a strict manufacturer’s warranty good for the first year. Regular wear and tear or destruction is not covered. Contact lenses must be paid in full at time of ordering and are non-refundable. Please note the contact lens fitting fee covers contact lens service (3 sets of trial lenses and 2 week check-ups) for a maximum of 3 months from date of FITTING. Additional fees will be charged for service that exceeds this time limit.

Contact Lens Evaluation Fee Contact lenses must be paid in full at time of ordering and are non-refundable. Please note the contact lens fitting fee covers contact lens service (3 sets of trial lenses and 2 week check-ups) for a maximum of 2 months from date of FITTING. Additional fees will be charged for service that exceeds this time limit. According to the FDA, all contact lenses are considered a MEDICAL DEVICE, since they are inserted directly into your eyes. Therefore, every year, if you want to purchase contacts or get a prescription for them, even if your prescription does not change, you must get a new evaluation for eye health purposes. This fee is separate from your regular exam fee that includes your eyeglass prescription and is inclusive of all contact lens related follow up visits within (6) months. Depending on the complexity of your prescription, the type of contact lens therapy, and your insurance coverage if applicable, this non-refundable fee can range from $75 and up.

*I understand and agree to the office policy as listed.

LIFETIME Patient Signature: Date: