Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Widowed	Employer / School Name
Misc/Guardian

Is the Billing Address Different?

Billing Information

Address Same As Above

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Vision Insurance

Primary Vision Insurance Information

Insurance Name:	None 90 Degree Benefits - 90 Degree Benefits AARP Medicare Advantage HMO - AARP Medicare Advantage HMO AARP Medicare Advantage PPO - AARP Medicare Advantage PPO AETNA HMO AETNA HMO- EXXON MOBIL AETNA MEDICARE HMO AETNA MEDICARE PPO Aetna TRS AETNA US HEALTHCARE Aetna Whole Health Accountable Care Network(HMO) ALL SAVERS ALLEGIANCE- CIGNA NETWORK ALLIED- Cigna Network ALLIED BENEFIT SYSTEMS American National Insurance Co. AMERIGROUP SOLUTIONS AMERITAS BCBS DISCOUNT PLAN/EYEMED BCBS HMO Blue Cross Blue Shield of Texas BLUE MEDICARE HMO BLUE MEDICARE PPO BOON CHAPMAN Christian Brothers Services/HBS Cigna Global Health Options CIGNA HEALTHCARE - CIGNA HEALTHCARE Cigna True Choice Medicare PPO - Cigna True Choice Medicare PPO Community Health Choice - Community Health Choice Continental Benefits - Continental Benefits EMI Health- Cigna Network - EMI Health Eyemed - EYEMED Eyequest Eyetopia - EYETOPIA Freedom Life-UMR - FREEDOMS LIFE-UMR GEHA- UHC Shared Services - GEHA Golden Rule - GoldenRule Harvard Pilgrim Health Care - Harvard Pilgrim Health Parnters - Health Partners HealthSmart Benefit Solutions(PHCS) - HealthSmart Humana Choice Care - Humana Choice Care Humana Gold Choice(Medicare Advantage) - Humana Gold Choice Humana Medicare TRS - Humana Medicare TRS Lasso Healthcare Medicare Advantage - Lasso Healthcare Loomis Company - Loomis Company Mail Handler Benefit Plan Manhattan Life Assurance Medicare Part B Medicare Supplement Memorial Hermann Health Solutions - Memorial Hermann Health Solutions Memorial Hermann Medicare Advantage Meritain Health - Meritain Health MISCELLANEOUS INS. NALC Health-Cigna Network - NALC Health PHCS - PHCS RR Medicare - Railroad Medicare Spectera - SPECTERA Superior Vision(Versant) Texas School Health Benefits - Texas School Health Benefit TML Intergovernmental Tricare Military Triwest - Triwest Trustmark Benefits- Cigna Network - Trustmanrk Benefits UHC TRS Care Medicare Advantage UMR - UMR UnitedHealthCare - UnitedHealthcare US Family Health Plan(Christus Health) - US Family Health Plan Vision Service Plan - Vision Service Plan
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Vision Insurance Information

Insurance Name:	None 90 Degree Benefits - 90 Degree Benefits AARP Medicare Advantage HMO - AARP Medicare Advantage HMO AARP Medicare Advantage PPO - AARP Medicare Advantage PPO AETNA HMO AETNA HMO- EXXON MOBIL AETNA MEDICARE HMO AETNA MEDICARE PPO Aetna TRS AETNA US HEALTHCARE Aetna Whole Health Accountable Care Network(HMO) ALL SAVERS ALLEGIANCE- CIGNA NETWORK ALLIED- Cigna Network ALLIED BENEFIT SYSTEMS American National Insurance Co. AMERIGROUP SOLUTIONS AMERITAS BCBS DISCOUNT PLAN/EYEMED BCBS HMO Blue Cross Blue Shield of Texas BLUE MEDICARE HMO BLUE MEDICARE PPO BOON CHAPMAN Christian Brothers Services/HBS Cigna Global Health Options CIGNA HEALTHCARE - CIGNA HEALTHCARE Cigna True Choice Medicare PPO - Cigna True Choice Medicare PPO Community Health Choice - Community Health Choice Continental Benefits - Continental Benefits EMI Health- Cigna Network - EMI Health Eyemed - EYEMED Eyequest Eyetopia - EYETOPIA Freedom Life-UMR - FREEDOMS LIFE-UMR GEHA- UHC Shared Services - GEHA Golden Rule - GoldenRule Harvard Pilgrim Health Care - Harvard Pilgrim Health Parnters - Health Partners HealthSmart Benefit Solutions(PHCS) - HealthSmart Humana Choice Care - Humana Choice Care Humana Gold Choice(Medicare Advantage) - Humana Gold Choice Humana Medicare TRS - Humana Medicare TRS Lasso Healthcare Medicare Advantage - Lasso Healthcare Loomis Company - Loomis Company Mail Handler Benefit Plan Manhattan Life Assurance Medicare Part B Medicare Supplement Memorial Hermann Health Solutions - Memorial Hermann Health Solutions Memorial Hermann Medicare Advantage Meritain Health - Meritain Health MISCELLANEOUS INS. NALC Health-Cigna Network - NALC Health PHCS - PHCS RR Medicare - Railroad Medicare Spectera - SPECTERA Superior Vision(Versant) Texas School Health Benefits - Texas School Health Benefit TML Intergovernmental Tricare Military Triwest - Triwest Trustmark Benefits- Cigna Network - Trustmanrk Benefits UHC TRS Care Medicare Advantage UMR - UMR UnitedHealthCare - UnitedHealthcare US Family Health Plan(Christus Health) - US Family Health Plan Vision Service Plan - Vision Service Plan
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance

Primary Medcial Insurance Information

Insurance Name:	None 90 Degree Benefits - 90 Degree Benefits AARP Medicare Advantage HMO - AARP Medicare Advantage HMO AARP Medicare Advantage PPO - AARP Medicare Advantage PPO AETNA HMO AETNA HMO- EXXON MOBIL AETNA MEDICARE HMO AETNA MEDICARE PPO Aetna TRS AETNA US HEALTHCARE Aetna Whole Health Accountable Care Network(HMO) ALL SAVERS ALLEGIANCE- CIGNA NETWORK ALLIED- Cigna Network ALLIED BENEFIT SYSTEMS American National Insurance Co. AMERIGROUP SOLUTIONS AMERITAS BCBS DISCOUNT PLAN/EYEMED BCBS HMO Blue Cross Blue Shield of Texas BLUE MEDICARE HMO BLUE MEDICARE PPO BOON CHAPMAN Christian Brothers Services/HBS Cigna Global Health Options CIGNA HEALTHCARE - CIGNA HEALTHCARE Cigna True Choice Medicare PPO - Cigna True Choice Medicare PPO Community Health Choice - Community Health Choice Continental Benefits - Continental Benefits EMI Health- Cigna Network - EMI Health Eyemed - EYEMED Eyequest Eyetopia - EYETOPIA Freedom Life-UMR - FREEDOMS LIFE-UMR GEHA- UHC Shared Services - GEHA Golden Rule - GoldenRule Harvard Pilgrim Health Care - Harvard Pilgrim Health Parnters - Health Partners HealthSmart Benefit Solutions(PHCS) - HealthSmart Humana Choice Care - Humana Choice Care Humana Gold Choice(Medicare Advantage) - Humana Gold Choice Humana Medicare TRS - Humana Medicare TRS Lasso Healthcare Medicare Advantage - Lasso Healthcare Loomis Company - Loomis Company Mail Handler Benefit Plan Manhattan Life Assurance Medicare Part B Medicare Supplement Memorial Hermann Health Solutions - Memorial Hermann Health Solutions Memorial Hermann Medicare Advantage Meritain Health - Meritain Health MISCELLANEOUS INS. NALC Health-Cigna Network - NALC Health PHCS - PHCS RR Medicare - Railroad Medicare Spectera - SPECTERA Superior Vision(Versant) Texas School Health Benefits - Texas School Health Benefit TML Intergovernmental Tricare Military Triwest - Triwest Trustmark Benefits- Cigna Network - Trustmanrk Benefits UHC TRS Care Medicare Advantage UMR - UMR UnitedHealthCare - UnitedHealthcare US Family Health Plan(Christus Health) - US Family Health Plan Vision Service Plan - Vision Service Plan
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Medical Insurance Information

Insurance Name:	None 90 Degree Benefits - 90 Degree Benefits AARP Medicare Advantage HMO - AARP Medicare Advantage HMO AARP Medicare Advantage PPO - AARP Medicare Advantage PPO AETNA HMO AETNA HMO- EXXON MOBIL AETNA MEDICARE HMO AETNA MEDICARE PPO Aetna TRS AETNA US HEALTHCARE Aetna Whole Health Accountable Care Network(HMO) ALL SAVERS ALLEGIANCE- CIGNA NETWORK ALLIED- Cigna Network ALLIED BENEFIT SYSTEMS American National Insurance Co. AMERIGROUP SOLUTIONS AMERITAS BCBS DISCOUNT PLAN/EYEMED BCBS HMO Blue Cross Blue Shield of Texas BLUE MEDICARE HMO BLUE MEDICARE PPO BOON CHAPMAN Christian Brothers Services/HBS Cigna Global Health Options CIGNA HEALTHCARE - CIGNA HEALTHCARE Cigna True Choice Medicare PPO - Cigna True Choice Medicare PPO Community Health Choice - Community Health Choice Continental Benefits - Continental Benefits EMI Health- Cigna Network - EMI Health Eyemed - EYEMED Eyequest Eyetopia - EYETOPIA Freedom Life-UMR - FREEDOMS LIFE-UMR GEHA- UHC Shared Services - GEHA Golden Rule - GoldenRule Harvard Pilgrim Health Care - Harvard Pilgrim Health Parnters - Health Partners HealthSmart Benefit Solutions(PHCS) - HealthSmart Humana Choice Care - Humana Choice Care Humana Gold Choice(Medicare Advantage) - Humana Gold Choice Humana Medicare TRS - Humana Medicare TRS Lasso Healthcare Medicare Advantage - Lasso Healthcare Loomis Company - Loomis Company Mail Handler Benefit Plan Manhattan Life Assurance Medicare Part B Medicare Supplement Memorial Hermann Health Solutions - Memorial Hermann Health Solutions Memorial Hermann Medicare Advantage Meritain Health - Meritain Health MISCELLANEOUS INS. NALC Health-Cigna Network - NALC Health PHCS - PHCS RR Medicare - Railroad Medicare Spectera - SPECTERA Superior Vision(Versant) Texas School Health Benefits - Texas School Health Benefit TML Intergovernmental Tricare Military Triwest - Triwest Trustmark Benefits- Cigna Network - Trustmanrk Benefits UHC TRS Care Medicare Advantage UMR - UMR UnitedHealthCare - UnitedHealthcare US Family Health Plan(Christus Health) - US Family Health Plan Vision Service Plan - Vision Service Plan
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

PATIENT INFORMATION

Referred by:
Family Members:
Last Eye Doctor/Phone:
Family Doctor/Phone:
Endocronologist/Phone:
Pharmacy Name:
Pharmacy Number:
* Race:	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other
* Preferred Language:	English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other
* Ethnicity:	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
* Gender:

Social History (required for insurance)

* Do you smoke?  Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other
Have you been infected with: HIV    Herpes Simplex    Hepatitis

Height:
* Ft. * In.
Weight:
* Lbs.
Have you ever had any surgeries?


REVIEW OF SYSTEMS (required for insurance) Place check beside the following that apply or mark NONE below:

Constitutional (fever, weight gain/loss)
Ear/Nose/Throat (Hearing loss, Sinus)
Neurological (migraines)
Endocrine (thyroid, diabetic)
Respiratory/Pulmonary (asthma, bronchitis)
Cardiovascular, Vascular (Blood Pressure, cholesterol)
Gastrointestinal (colitis, crohns disease)
Genitourinary (bladder, prostate)
Bones/Joints(joint pain, rheumatoid arthritis)
Lymphatic/Hematologic (anemia, bleeding)
Allergic/Immunologic (sjogrens)
Psychiatric (depression)
NONE

MEDICAL HISTORY

* Are you allergic to any medications?
NO KNOWN    Yes

Please list:
List all current medications:
None

Please check if any of the following pertain to you:

Pulmonary Disease    Asthma    Diabetes    Hypertension    COPD    Heart Problems

* Are you Pregnant or nursing?   NO    Yes

GENERAL HEALTH:

Do you feel that your general health is:   Good    Poor    Fair

Family Medical History: Cancer Hypertension Arthritis Asthma Diabetes COPD

Eye History

Eye History (Are you experiencing any of the following symptoms?

* Please check all that apply.

Dryness Tearing Sty Double Vision	Blurred Vision Discharge Light Sensitivity Eye Lid Itch	Glare Flashers/Floaters Foreign Body Sensation Eye Pain	Droopy Eyelid(s) Eyeball Itch Variable Vision Redness	Sting, Burn Loss of Lashes Distorted Vision
Other:

Have you had any eye surgery, laser treatments or eye injury?
No    Yes
If yes, please explain:

* Have You been diagnosed with Diabetes?
Yes No Type 1 Type 2 Pre - Diabetes
Have you been prescribed eye drops?
No    Yes

If yes, what drops and how often:

* Do you wear prescription glasses?
Yes NO
When do you wear your glasses?
All the time    Computer    Reading/Near     Distance Only

Other:

How old is this prescription?


Do you see well with this prescription?
No    Yes

Do you wear contacts? If so what brand:


* Right Eye RX:
* Left Eye RX:

Are you interested in contacts? No    Yes

What type of glasses would you like and for what types of activities:

FAMILY HISTORY

Do you or a blood relative have:

	Self	Relative
Glaucoma	NO   Yes	NO   Yes
Cataracts	NO   Yes	NO   Yes
Lazy Eye	NO   Yes	NO   Yes
Retinal Disease	NO   Yes	NO   Yes
Macular Degeneration	NO   Yes	NO   Yes
Corneal Disease	NO   Yes	NO   Yes

Patient Signatures / Submit Data

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Policies and Consent

View Policies and Consent Form

* have read and agree to the policies outlined above.

*Patient Signature: *Date: