Online Patient Forms

Patient information

First name

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Last name

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Nickname

Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Vision Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

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Medical History

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Eye History

Reason for Visit

Primary Reason

Secondary Reason

Do you currently have any of these eye symptoms?

Do you currently take any of these medications?

Have you had any eye surgeries? Please describe

Last Eye Exam

Last Appointment Type

By Doctor

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Medical History:

Medications No Medications

Over the Counter Medications

Vitamins

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?

Diabetes

Hypertension

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Year Diabetes Diagnosed

Other

Family Medical History

Unknown Family History

Does anyone in your family have any of these medical conditions?

Hypertension

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

Does anyone in your family have any of these eye conditions?

Macular Degen

Glaucoma

Retinal Detach

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

Policies, Consent, Submit Data

**Click here to view the HIPAA Privacy Policy**

I have been given the opportunity to read the HIPAA Privacy Policy.*

Patient Responsibility

There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts both:

-Vision care plans: such as VSP and EyeMed
-Medical insurance: such as Blue Cross/Blue Shield and Medicare

Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases.

Medical insurance must be used if you have any eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history.

If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense.

We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract. For glasses orders, once your order is finalized, full payment of the glasses is expected at the time of service. Once the order is submitted to the lab, lens changes and refunds are not allowed.

I have read and agree with these policies.

Patient Name:

Patient Signature / Legal Guardian:

Date:

Reviewed HIPAA Notice of Privacy Practices:

Patient Name:

Patient Signature / Legal Guardian:

Date: