Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information


Title First Last MI Suffix Nickname
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 Favorite Candy:
Current favorite artist/jam:

Billing Information

Is The Billing Address The Same?
Title First Last MI Suffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

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 Reason For Visit: Please list any other eye concerns/issues:

Please list any eye condition/disease that you've been diagnosed with along with any eye surgeries and the date:
Please list any eye medications or eye drops you are currently taking:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses?

Interested In Glasses?
Interested In Contact Lens?
Interested In Laser Vision Correction?

Medical History

Medications:
Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing:


Family Eye History

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

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

Review of Systems

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

Dry Eye Questions (>15 Years Old)

Do your eyes ever feel dry, gritty or uncomfortable?
Are you bothered by persistent redness and irritation?
Do you feel the need to use artificial tears daily?
Have you ever been diagnosed with facial rosacea?
Have you ever been on the medication accutane?

Trilift Questions (>40 Years Old)

Would you like your eyes to look more open or rested?
Have you noticed puffiness, drooping, or heaviness around your eyes or face that bothers you?
Are you interested in non-surgical ways to help with lifting and tightening the skin around your eyes and face?

Social History

Hobbies:

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

Race: Ethnicity: Preferred Language:

Submit Form / Patient Signatures

NOTICE OF PATIENT PRIVACY RIGHTS, PROTECTION, AND RESPONSIBILITIES


Important Information Regarding Your Upcoming Appointment

CO-PAYS & INSURANCE

I understand that I am responsible to pay all co-payments at the time of service. Co-payments cannot be waived at any time by Eyes on Westlake. Please provide your vision and medical insurance details at least 24 hours before your appointment, including any updates. We're unable to file claims retroactively. Missed appointments without a 24-hour courtesy notice will incur a $45 fee. Insurance benefits are estimates and not guaranteed-if any services or materials aren't covered, you'll be responsible for the balance, payable within 30 days. If you don't have medical insurance but require a medical exam, please note that your visit will be out of pocket. We take pride in our services and the personalized care we provide. All professional fees are non-refundable. Any fees, co-pays, deductibles, and contact lens evaluation fees (if not covered by insurance) are due at the completion of your exam.

REFUNDS, REMAKES & WARRANTIES

Our office sells custom-made products and therefore cannot issue a full refund for glasses once they have been ordered. If you need to cancel, a restocking fee will apply. We offer a one-time, 60-day remake policy to adjust lens options, address non-adapts, or change frames or prescriptions. Additional remakes may have associated fees. We believe in using the best-quality materials and extend the manufacturer's 2-year scratch warranty on all lenses. If you bring your own frame, please know that materials can weaken over time, and while we handle them with care, we can't be responsible for accidental breakage.

OPTOMAP RETINAL IMAGING

To ensure the highest standard of care, we perform Optomap retinal imaging on all comprehensive exams for $49. This state-of-the-art technology allows us to detect sight-threatening and systemic conditions such as diabetes, high blood pressure, retinal tears and even cancer in just seconds-without the discomfort and extended time required for dilation drops. We believe it is the best way to evaluate your ocular health and it is our practice's standard of care. You will be able to view your own retinal images and this will serve as a permanent record to track and compare over time. If the cost is prohibitive, please inform our team in advance.

HIPAA & PRESCRIPTIONS

Your privacy matters to us. Under HIPAA, your health information is protected and may be used for treatment, payment, and healthcare operations. I understand that I will receive a copy of my glasses prescription at the end of my exam. I consent to also receiving both my glasses and contact lens prescriptions digitally via the patient portal.

Thank you for trusting us with your eye care-we appreciate you and look forward to seeing you soon!

AGREEMENT


Patient Signature/Guardian: Date:

Please list the name of any individuals we are able to share or discuss your medical information with below: