Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

Home Phone

Preferred Contact Method

Birthday

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

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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

STD

Policies, Consent, Submit Data

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

Notice of Privacy Practices

-View Notice of Privacy Practices Form-

Additional Testing / Vision Vs Medical / Patient Responsibility

-View Additional Testing / Vision Vs Medical / Patient Responsibility-

Additional Testing - FOR SELF PAY AND VISION INSURANCE PATIENTS

OCT SCREENING includes RETINAL IMAGING - $64.00 I elect to have these tests. I understand there is a $64 charge that is NOT covered by my insurance.

Virtual Reality Visual Field Screening - $50.00 Yes, I elect to have these tests. I understand there is a $50 charge that is NOT covered by my insurance.

DILATION of the pupil - $30.00 I understand the risks and benefits, understand the side effects, and I consent to have the procedure.

NO DILATION I waive all liability towards the Doctor and John DU OD PC for this decision.

External Photography - Meibography - $25

I WOULD LIKE MORE INFORMATION ON:

IPL - PHOTO FACIAL - Intense pulse light - NEW DRY EYE Treatment

Myopia Managment

Zest - EYELASH Treatment

PATIENT RESPONSIBLITY : VISION VS MEDICAL INSURANCE
2 Types of insurances that will help pay for your eye care services. You may have both and we accept both.
VISION care plans ( Eyemed, Aetna vision, Spectera, Cigna Vision, VSP, Davis Vision )
Only cover routine vision exams / basic screenings. Do not cover diagnosis, management or treatment of eye diseases.
MEDICAL Insurance (Aetna, Carefirst, BCBS, Anthem, UHC, Cigna, Medicare)
(Diabetes, Cataracts, Dry Eye, Pink Eye, Floaters, etc.) Ocular complications from any health problem or systemic health problem. The doctor will determine if these conditions apply, based on your case history. VISION care plans ( Eyemed, Aetna vision, Spectera, Cigna Vision, VSP, Davis Vision ) Only cover routine vision exams / basic screenings. Do not cover diagnosis, management or treatment of eye diseases. If necessary, services will be submitted to both medical and vision plans if we are participating providers. Coordination of benefits will be used and may minimize your out-of-pocket expense. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services in accordance by the insurance contract. Insurance carriers set these rules and our office is obliged to follow them.

I agree that I have been given access to John Du O.D. P.C. Notice of Privacy Practices/ (HIPAA) Policies. I further agree to pay all applicable exam charges at time of visit. All services are Rendered. I understand my insurance will not be accepted if presented after exam and will not be refunded. I understand if my records are sent via fax, mail, any email transmissions, or by any other methods other than physically handing the records to you, unintended persons may access your medical information. You agree, understand, and have read the explanations located on 2nd laminated page to dilation, OCT / retinal screenings and visual fields before signing. By signing this you confirm you will receive a written prescription for your glasses or contact lens once finalized by the doctor. 90 DAY WARRANTY RX changes

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