Online Patient Form

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Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Primary Vision

Insurance Information
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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Primary Medical

Insurance Information
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:
Sex:
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!

Eye History

Reason for Visit:
Primary Reasons: Secondary Reasons:

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: Last Appointment Type 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:

Medical History

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

Family Medical History



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

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

Family Eye History

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

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

Review of Systems

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

Social History

Hobbies:

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

Race: Ethnicity: Preferred Language:
STD

Patient Signatures

COVID-19 CONSENT

Due to the COVID-19 pandemic, we are taking extra precautionary steps in order to protect our staff and patients. In addition to the standard precautions of hand washing and sanitizingequipment after each patient interaction, we will also be using face masks, gloves and face shields as well as taking temperatureson each person who enters the office. Any person who has a temperature over 99 degrees will be required to reschedule their appointment. We require face masks for anyone who enters our office; the face mask must cover theirnose and mouth. Only patients are allowed in the office. Other people, such as spouses, children, friends or any significant others must stay within their car while the patient is being seen for their eye exam. The only exception would be for minors under the age of 18 and those people who require a language translator. If you are not feeling well, display any symptoms associated with COVID-19, have travelled in the last 14 days or have been in contact with any confirmed or suspected cases of COVID-19, please reschedule your appointment. By signing below, I agree that I will not hold Master Eye Associates/Mai Nguyen OD PLLC responsible should I, or someone I come in contact with, become positive or presumptively positive for COVID-19. There are certain inherent risks associates with an eye exam during a pandemic and I assume full responsibility for personal illness that may result, and further release and discharge Master Eye Associates/Mai Nguyen OD PLLC for illness, injury, loss or damage arising from my visit. I understand that COVID-19 infection can lead to illness, disability or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision and my health.

Patient Signature: Date:

AUTHORIZATION

I authorize the optometrist to release any information including the diagnosis and the records of any treatment or examination rendered to me (or my child) during the period of such eye care to third party payers and/or health practitioners. I authorize my doctor to act as my agent in helping me obtain payment from my insurance companies and I request my insurance company to pay directly to Mai Nguyen OD PLLC. I understand that my insurance carrier may pay less than the actual bill for services.I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that all visits to this office are payable at the time of service. I authorize payment directly to my doctor. I understand that all examination fees and copayments are due when service is rendered and are NON-REFUNDABLE.

Patient Signature: Date:

EXAMINATION POLICY

If necessary, you will have 60 days from your last complete exam date for a glasses prescription re-check at no cost. All contact lens services are separatefrom the routine eye exam. By law in Texas, contact lens prescriptions are valid for one year. Disposable trial lenses are for fitting purposes only and will be dispensed only at the initial fittingexamination. This excludesany contact lens upgrades OR medical problems, which will be billed accordingly. You have 60 days from the initial exam date to return for a contact lens upgrade in which you will be responsible for paying the difference in fees. Once the contact lens prescription is finalized, we reserve the right to charge additional fees for any contact lens re-fits or upgrades.

Patient Signature: Date:

CONTACT LENS AGREEMENT

Contact lens wear can improve the quality of life but also poses some risks and limitations. You must take propercare of your lenses and know what to do in the event of a problem. It is essential that you follow instructions as directed by your optometrist to avoid any potential risks. As with prescription medications, contact lenses can only be dispensed pursuantto a prescription by an eye care practitioner with a limit on the supply of lenses to be purchased before an expiration date. Your optometrist will recommend a specific wearing, replacement and follow-up schedule. Remove your contact lenses and call ouroffice immediately if you experience any of the following symptoms: eye pain/irritation, sensitivity to light, eye redness, stinging, burning, excessive tearing, discharge, blurry vision or disturbance of vision.

I have read this document carefully and fully understand the importance of the Doctor's recommendations. The contact lens examination fee covers all routine follow-up visits for no additional charge for 60 DAYS after your full exam. Additional examination after 60 days of the initial contactlens examination will result in an additional charge of $25.00 per visit.

Patient Signature: Date:

ACKNOWLEGEMENT OF PRIVACY PRACTICES

I acknowledge that I have read and understand the Notice of Privacy Practices. I understand that this office is HIPPA compliant. I hereby acknowledge that the HIPPA policies are posted and available for me to read.

By signing below, I agree that I have read the above and consent to the use and disclosure of my health information for purposes of treatment, payment and health operations. I understand I am financially responsible for all charges incurred by myself and/or my dependents.

Patient Signature: Date:

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