Online Patient Questionnaire

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

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

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!

Medical History

Please choose from the menu options

Eye History

Reason for Visit

Primary Reason

Secondary Reason

Do you currently have any of these 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

Last Visit

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?

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

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

Unknown family eye history

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

Please complete every field. For example, if you do not have Endocrine disease, please select "None" rather than just leaving the field blank.

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

PATIENT FEES & RESPONSIBILITY

Please note that full payment of co-pays, overages, non-covered items, etc. is required at the time services are rendered. Verification of eligibility and authorization numbers from your insurance company is not a guarantee of payment. The final determination of payment is made when the insurance company receives your claim. Any fee that your insurance does not cover is your responsibility. If insurance reimbursements are not made back to our office within 30 days, then the entire balance becomes your responsibility. Please understand that insurance filing is a courtesy, and you are ultimately responsible for knowing your insurance benefits.

Per the Department of Health & Human Services Evaluation and Management Services Guide, Ã¢ÂÂThere are three key components when selecting the appropriate level of E/M service provided: history, examination, and medical decision making. Visits that consist predominantly of counseling and/or coordination of care are an exception to this rule. For these visits, time is the key or controlling factor to qualify for a particular level of E/M servicesÃ¢ÂÂ. So, if you would like to speak to the doctor regarding something, even if an examination is not performed during that time, an office visit will be charged for the doctorÃ¢ÂÂs time as stated in the Evaluation and Management Services Guide from the Department of Health & Human Services.

A refraction may be performed to evaluate if any further visual improvement can be achieved during a medical office visit. However, the refraction is considered a non-covered service by Medicare and medical insurances. The refraction fee is in addition to the fee for medical office visit and is in addition to your co-pay, and must be paid before the patient is seen by the doctor.

If using insurance, I hereby authorize the provider to release any information required to process my insurance claim. I also authorize my insurance benefits to be paid directly to Bright Eye Care & Vision Development. I understand that I am fully responsible for any fees that my insurance will not pay. Regardless of whether I am using insurance, I also understand and agree that no refunds will be given for any product, whether I pick up the product or not, or service because of the personalized nature of healthcare. I also understand and agree that there is no warranty or refund on broken or lost eyewear. I also agree and understand that there are no refunds for services or products. I agree to and understand all that is written in this document, and understand that this document holds true beginning today and for all subsequent visits and transactions in the future.

Patient Signature

*This field is required

Date

What is the major purpose of this visit?:

This will help determine what type of exam you will need. If you are here for a medically related issue - red eye, painful eye, etcÃ¢ÂÂ¦ - then you will need an office visit. If you are here to check for the need for glasses, then you will need a yearly eye exam. If you need a contact lens exam, then that would be a different type of exam. Each type of exam requires a different fee. Please direct any questions about fees to the front staff. The doctors will not discuss fees.

Describe:

Dilation

Dilation during a routine yearly eye exam does not check for eye diseases because those conditions are not routine. If you have a known eye disease or a medical concern involving the eyes, separate diagnostics and medical decision-making will necessitate a medical office visit as opposed to a yearly eye exam with dilation to investigate the disease process or concern. For example, if you are concerned about diabetes in the eye, you will need to schedule a medical office visit with us rather than just receiving a dilation with your yearly eye exam. Once dilated, you will be sensitive to sunlight and will not be able to read clearly for the next four to five hours. A pair of temporary sunglasses will be provided to help reduce sensitivity to light.

I understand & agree with the above statement.

I would like to (please check a box):

decline

go forward with the dilation

Patient Signature

Date