Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

*This field is required

Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

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:

Please choose from the menu options or select the option to type in your own text. Thank you!

Eye History

What is the main reason for your visit today?

Do you currently have any of these symptoms?

Do you currently take any of these eye medications?

Please list any eye surgeries and/or trauma (include dates)

Last Eye Exam

By Doctor

Ophthalmologist

Last Visit

Primary Vision Correction

What type of glasses do you wear?

How old are your glasses?

Do you wear contacts?

*This field is required

Contact Lens Wearers Only

What solution do you use?

Do you have backup glasses?

How often do you sleep in your contacts?

How often do you replace your contacts?

Family Eye History

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

Unknown family eye history

ARMD

Glaucoma

Retinal Detachment

Blindness

Retinal Dystrophy

Strabismus

Medical History:

Medications No Medications

Drug Allergies No known drug allergies

Vitamins

Over the Counter Medications

Please describe any injuries or surgeries you have had:

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Do you have any of these medical conditions?

Diabetes

Year Diabetes Diagnosed

HbA1c

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?

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

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

STDs

Policies, Consent, Submit Data

Notice Of Privacy Practices

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

View Notice Of Privacy Practices Form

Patient Signature

Date

FINANCIAL RESPONSIBILITY

I acknowledge that I am responsible for all charges for services and materials provided, including the amount not covered by insurance plans. All services and materials provided are due and payable at the time of service or order. I understand that my insurance policy is an agreement between me and my insurance company. If payment from my insurance company is insufficient to settle my bill in full, the remaining balance and payment will remain my responsibility. All monthly statements are due and payable within 30 days. Any outstanding balances, after 30 days will accrue at a 1.5% monthly late fee. If my account remains unpaid after 120 days and payment arrangements were not made prior, my account may be placed into collections or small claims court.

Patient Signature

Relation To Patient

Date

AUTHORIZATION TO ASSIGN INSURANCE BENEFITS

I authorize billing and payment of medical benefits to Laguna Eyes Optometry, P.C. and Slow the Game Down for all services rendered during my visit. I understand that I am financially responsible for all charges, whether or not theses are covered by my insurance. I authorize Laguna Eyes Optometry, P.C. and Slow the Game Down to release all information necessary to secure payment from my insurance company on my behalf.

Patient Signature

Relation To Patient

Date

Communication Preferences

Please provide best number/email:

Is it okay to leave a voicemail at this number?

I approve Laguna Eyes Optometry, PC to communicate with the following people about my eyecare and/or release my products to the following people without prior authorization:

Name:

Relationship:

Phone Number:

Email:

Name:

Relationship:

Phone Number:

Email:

Name:

Relationship:

Phone Number:

Email:

Emergency Contact(This Person To Be Contacted In Medical Emergency.)

Name:

Relationship:

Phone Number:

Email: