EYELAND VISION LOGO

Thank you for choosing EyeLand Vision for all your eye care needs. EyeLand Vision?s reason for existence is to PRESERVE, ENHANCE and PROTECT eyesight. A through medical and eye history will allow us to fulfill our reason for existence.
Please click on each tab, from left to right, enter your information requested and after completing all forms, click on the SUBMIT tab. For each field on this form, if you do not see an appropriate descriptive dropdown, select 'Other' and the field will allow you to type in your answer.

Patient Information

General Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical Insurance

Medical Insurance Information
Insurance Name:
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:
Vision Insurance Information
Insurance Name:
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 Insurance Information
Insurance Name:
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:
Please complete the next tab 'Medical and Eye History'

Medical and Eye History


        Whom may we thank for referring you?    Referral's Address or Phone Number: 
        If you are a returning patient: Which reminder did you receive? 

        A. CHIEF VISUAL COMPLAINT

        What Brings You in Today?    Which Eye?:     Symptoms: 

        Onset:    Meds Used:    CL Wearer: 

        Secondary Complaint:    Notes: 

        B. EYE HISTORY

        Last Eye Exam:    Diagnosis:    Doctor Prescribed: 

        Last Eye Doctor's name:     Last Eye Doctor's Address:     Last Eye Doctor's Telephone: 

        Please check all eye conditions that apply to you:    Have you ever had any Eye surgeries? 
        Procedure Date: 

        Family Members with Eye Conditions (blood relatives only)
        My     Has  
        My     Has 
        My     Has  

        C. EYEGLASSES HISTORY  Do You Wear:

        Prescription EyeglassesSafety Glasses
        Prescription SunglassesSports Goggles
        Computer eyeglasses
        HOW OLD ARE YOUR CURRENT EYEGLASSES: 

        D. CONTACT LENS HISTORY

        Do you wear contact lenses?    If yes, What Brand? 
        How many hours a day do you wear your contacts? 

        How often do you dispose your contacts?     Do you Sleep or nap in contacts? 

        What solutions do you use to clean and disinfect your contacts?     Do you wear UV coated sunglasses? 

        E. GENERAL HEALTH HISTORY

        Last general health exam:          Doctor's name? 
        Doctor's Address:   Doctor's Phone: 

        Please Check all health conditions that apply to you:                 Family Members with health conditions (blood relatives only)
        Seasonal AllergiesHeadaches                              My     Has 
        ArthritisHeart Disease                              My     Has 
        AsthmaHIV                              My     Has 
        CancerHypertension
        DiabetesLung Disease
        SeizuresVascular disease

        Have you had any Medical Surgeries:

        F. MEDICATIONS

        I take   For        Please list any additional Medications: 

        I take   For        Please list any Medication Allergies: 

        I take    For 

        G. LIFESTYLE QUESTIONS

        These questions are intended to assist us in better meeting your everyday VISUAL needs.

        How many hours do you spend on a computer?    Reading / Deskwork? 

                                                                             Outdoors:          Nightime Driving? 

        Which Sports do you participate in?
        None                      Ice Skating              Football             Hunting
        Basketball             Martial Arts             Swimming         Water Skiing
        Baseball/Softball  Snow Skiing          Golf
        Fishing                    Soccer                    Tennis
        
        I want the style of my frames to be:   I want my frames to be made of: 
        I want my lenses to be: 
        Please select all your preferences from the following:
         Reflection/Glare Free         Transitions   Thin and Lite Weight
         UV Coated for Protection   Polarized Sunglasses to Reduce Glare   Aspheric Design to Reduce Coke Bottle Effect

        Has there been a time when you wish you were NOT wearing eyeglasses? 
        If yes, would you like to know if you are a candidate for contact lenses: 
        Are you interested in colored contacts: 
Please click on the 'Patient Signature' tab and complete it

Patient Signatures


        HIPAA Privacy Policy, Preferred Method of Contact, Financial Agreement and Consent to Treatment:
        Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

         View HIPAA Patient Privacy Policy Form
        How would you like our office to communicate with you? 
        Enter your cell#, email address, Home Phone, or Home Address:  

        * I have read, understood, received and accept Eyeland Vision's Privacy Policy regarding why you may contact me and how my health information is used and disclosed.
        **Please enter First and Last Name: 

        View Financial Agreement and Consent to Treatment Form
        *I have read, understood, received and accept Eyeland Vision's Financial Agreement and Consent to Treatment.
        **Please enter First and Last Name: 

        ** By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I
        accept has the same validity and meaning as my handwritten signature.

Thank you for trusting Eyeland Vision with the care of your eyes!
Congratulations! Now you can SUBMIT your data on the last tab.

Submit Data

Are you sure all of the information you gave us is correct? If so, please click Submit Data below.

Please bring your driver's license, all your insurance cards, and any glasses you wear to your appointment.