Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Birth Sex

Male Female

*This field is required

Full Address

*This field is required

City

*This field is required

State

*This field is required

Zip Code

*This field is required

Please enter only 10 digits, including the area code. Do not enter any dashes or spaces. Do not enter the number 1 in front of the phone number

Cell Phone

*This field is required

Birthday

*This field is required

Full SSN

*This field is required

If you don't have a Social Security Number, Please enter "None"

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

Primary Reason for visit

*This field is required

Location:

*This field is required

Severity:

*This field is required

Duration:

*This field is required

Context:

*This field is required

Do you currently have any of these eye symptoms?

*This field is required

What eye medications are you currently taking? If you are not taking any, please type "None" in the box

*This field is required

Ocular Surgery

*This field is required

Medical History:

Medications No Medications

*This field is required

Over the Counter Medications

Vitamins

Drug allergies No Known Drug Allergies

*This field is required

Do you have any of these medical conditions?

Diabetes

*This field is required

Hypertension

*This field is required

High Cholesterol

*This field is required

Thyroid Conditions

*This field is required

Heart Conditions

*This field is required

Cancer

*This field is required

Family Medical History

Unknown Family History

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

Hypertension

*This field is required

Diabetes

*This field is required

Thyroid

*This field is required

Cancer

*This field is required

High Cholesterol

*This field is required

Heart Conditions

*This field is required

Family Eye History

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

Macular degeneration

*This field is required

Glaucoma

*This field is required

Retinal detachment

*This field is required

Blindness

*This field is required

Cataracts

*This field is required

Lazy/Crossed Eye

*This field is required

Social History

Smoking Status

*This field is required

Preferred Language

*This field is required

Notice of Privacy, Policies and Agreement

Patient acknowledges that

It is the patient's responsibility to check if we are out-of-network with their insurance plan prior to their visit.
It is the patient's responsibility to file insurance claims if we are not contracted with your insurance company.

I understand that all charges for professional services rendered are my responsibility. I understand this office, if contracted with my insurance company, will file a claim to my insurance company on my behalf.

I authorize payment of benefits to Eric Verret OD, Inc.

Your doctor will accept the fee approved by your insurance as payment in full for any covered services. The patient will be responsible for any amount approved but not paid by the insurance as well as the full amount for all non-covered services.

I agree to assume responsibility for co-payments and deductibles as specified by my insurance and for the charges of any non-covered services.

I Agree

*This field is required

NOTICE OF PRIVACY PRACTICES

Please read our Notice of Privacy

I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices and that I will be offered a copy of any amended Notice of Privacy Practice at each appointment.

I Agree

*This field is required

RELEASE OF MEDICAL INFORMATION

I authorize release of my medical information to the following persons.

Name:

Phone number:

Relationship:

I Agree

Name:

Phone number:

Relationship:

I Agree

Name:

Phone number:

Relationship:

I Agree

PHYSICIAN PATIENT ARBITRATION AGREEMENT

please read our Patient Arbitration Agreement

I Agree

*This field is required

Signature:

*This field is required

Date:

Patient information

Billing information

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

Medical History:

Do you have any of these medical conditions?

Family Medical History

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

Family Eye History

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

Social History

Notice of Privacy, Policies and Agreement

Patient acknowledges that

NOTICE OF PRIVACY PRACTICES

RELEASE OF MEDICAL INFORMATION

PHYSICIAN PATIENT ARBITRATION AGREEMENT