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


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

Billing Information

Is The Billing Address Different?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

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:

Secondary 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:

Secondary 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

Submit Form / Patient Signature



Authorization and Consent

I certify that I have read and understand the Patient Information Sheet (dated ) to the best of my knowledge. The questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the eye doctor to release any information including the diagnosis and the records of any treatment of examination rendered to my child or me during the period of such eye care to third party payers and/or health practitioners.

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HIPPA/ High Tech Act Notification
HIPAA email consent

VERY IMPORTANT! PLEASE READ!

When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it. Records are permissible, however per Texas Optometry Board, Glasses and Contact lens prescriptions are only allowed to be faxed or e-mailed directly to dispensing facility.

I understand the risks of unencrypted email and do hereby give permission to Jack Rountree Eyecare to send me personal health information via unencrypted email.

Signature: Date:
Printed Name: Please Print Email Address:

This notice describes how medical information about you may be used and disclosed and how you can get access to this information be it by written, mail, fax or email. Please review it carefully. Your point of contact about your rights to access your Health Records or complaints and comments about your health record privacy is:

Jack Rountree Eyecare HIPAA Director
5025 NW Loop 410
San Antonio, Tx 78229

You may file a complaint with the Director of HHS. We will use your Protected Health Information to provide appointment reminders, describe or recommend treatment alternatives and provide information about health related benefits and services that may be of interest to you. We will maintain the privacy of your health records, provide this Notice to you, abide by the terms of this Notice and reserve the right to revise the privacy practices of this office. You have the right to review or to copy your health records, request changes or offer amendments to your records, obtain a accounting of to whom we have disclosed information from your records and request restrictions on certain uses and disclosures from your health records. You also have the right to revoke our ability to disclose your health information by providing the practice with a signed written request. Until such a request is received, this Notice will be in effect for seven years from the date of the most recently signed Notice.

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Dilation of the Pupils

Dilation of pupils is included as a part of your full annual eye exam. If you have a condition such as diabetes, high blood pressure, cataracts, headaches, high myopia (nearsightedness), symptoms of flashes of lights of floaters, glaucoma or a family history of glaucoma, dilation is even more an important part of your eye exam. By dilating your pupils, many diseases both in your eyes and body can be detected long before any signs or symptoms arise. Dilation involves placing drops in your eyes to enlarge the pupil size.

With dilation of the eyes you may experience the following effects:
  • Increased sensitivity to light
  • A slight blurring of your distance vision
  • Inability to focus up close

    •  These effects may last from 1 to 4 hours.

    Please check one of the following options and sign below:

    YES I do consent to having my eyes dilated.

    NO I do not wish to have it performed at this time, yet I do understand the importance of the dilation. I release Dr. Jack Rountree from any liabilities related to the failure to diagnose or treat any eye condition due to the lack of diagnostic information which could have been obtained by the test.

    X Initials

    Payment Policy: Payment is expected at the time services are rendered. When insurance benefits are verified, the information provided by the customer service representative is not a guarantee of payment. There may be additional fees for co-pays, deductibles and non-covered services after payment is received from the insurance company. By signing this statement, you agree to be financially responsible for any and all charges.

    Assignment of Benefits: (Only applicable if we are filing with a Vision or Medical Insurance for you). “I hereby authorize my insurance/medical benefits to be paid directly to Dr. Jack Rountree. I further authorize release of any medical records or information necessary to process this claim”. This assignment of benefits may be revoked by the patient at anytime, with prior written notice.

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    Exam and additional charge form

    Annual exam fee is $69

    Office Visit fee (per visit) is $49

    Visual fields fee:

    Screening: $10
    Intermediate: $20
    Threshold: $30

    Contact lens Fit and Annual evaluation fee:

    Sphere: $30
    Astigmatism $50
    Monovision $70

    I understand that the contact lens fit and evaluation fee will be an annual reoccurring charge. Any add-on charges are due at the time of service.

    Signature (or parent / guardian): Date: