Online Patient Form

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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

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

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:

Tertiary

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:

Old Insurance 1

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 Signatures

OPTOS

During an annual eye exam, your doctors now strongly advise the new state-of-the-art technology optomap ultra-widefield retinal exam to monitor for complications including macular degeneration, diabetic retinopathy, glaucoma, and retinal holes or detachments. These problems can develop without warning and sometimes with no signs or symptoms.

This scan also allows your doctors to see a greater and detailed view that can assist with detecting systemic problems unrelated to the eye such as diabetes, hypertension, cancer/tumors, auto-immune disorders, and others.

The optomap Retinal Exam:

    * Is as fast as taking a picture.
    * Does not require dilating drops. Your doctor will determine whether you need to be dilated in addition today.
    * Saved in your file enabling our doctors to make important comparisons during your annual eye exam.

There is a $39.00 fee for the optomap Retinal Exam.

I agree that the optomap Retinal Exam will be performed today.

Signature:
Date:

CONSENT FORM

HIPAA POLICY
Portland Eyecare is required to provide confidentiality for all medical health records and other individually identifiable health information. Ways in which we may use or disclose your protected health information includes: 1. Treatment 2. Payment 3. Health Care operations. Uses and disclosures will be made only with your authorization. I have read and understand the full HIPPA guidelines. I give my consent for Portland Eyecare doctors or staff to leave messages on my provided phone number regarding scheduling, treatment or other information as necessary
Initial:

CONTACT LENS AGREEMENT
I understand that contact lenses are a medical device and require an annual prescription. An annual contact lens evaluation is mandatory to maintain an active contact lens prescription. This is true whether or not changes are made to the contacts. A training session is required for all first time contact lens wearers. This is an additional fee. The contact evaluation period can extend up to 60 days after your initial fitting. If after 60 days, a CLRx is not finalized, a new fitting will be performed. All contact lens fees are non-refundable.
Initial:

FINANCIAL RESPONSIBILITY
By initialing the above, you are agreeing to pay any amount your vision or medical insurance does not cover. This includes copays, contact lens associated fees, deductibles, and other services not covered by your insurance plan. You are responsible to obtain necessary referrals or prior authorizations needed. It is your responsibility to understand your insurance coverage. I understand that if my balance becomes delinquent and Portland Eyecare finds it necessary to place it with a collection agency, I will be responsible for the collection fee of 35% in the recovery of my account balance.
Initial:

ROUTINE VS. MEDICAL COVERAGE
There are two types of health insurances that will help pay for your eye care service: Vision plans and Medical plans. Vision care plans only cover routine vision exams. These plans cover your glasses prescriptions and do not cover diagnosing or managing ocular diseases, such as Dry Eye Disease, Diabetes or Glaucoma. The doctor will determine if a medical issue is diagnosed at the time of your exam. If so, vision plans do not cover any diagnostic testing associated with a medical diagnosis. In this case, your medical insurance will be billed. You are responsible for any copay, deductibles or out of pocket expenses. By initialing the above, I understand the difference between vision and medial plans and am responsible for any amount my insurance does not cover.
Initial:

Patient Name (Please type for consent):
Patient Representative (Please type for consent * If patient is under 18 years of age)