Online Patient Form

Click here to return to the previous website.

After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Birth Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian



Online Medical

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:

Online Vision

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:

Review Of Systems


Reason For Visit:
Secondary Reason
Primary Care Physician
Last Visit
Endocrinologist
Reumatologist
Pregnant or Nursing
Drug Allergies
Medications currently taking
List all major illnesses, injuries, surgeries, cancers, and hospitilzations within the last 10 years:

Check any ocular conditions or symptoms that may apply to you

Please note if you have a family history of these conditions


Blindness
Eye Turn / Lazy Eye
Glaucoma
Heart Disease
Macular Degeneration
Diabetes
Retinal Detachment
Cancer
Color Blindness
Condition
Relationship(s)

Please indicate special visual demands you may have:

Dusty Work Environment Football Computer Hours per Day
Sewing Baseball Reading Hours per Day
Gardening Basketball Video Games/ TV Hours per Day
Piano Soccer Water-Sports Fishing Vollyball
Other

Check any systemic conditions below which apply to you




Click here to view Hippa Form

All information on this form has been reviewed and corrected to the best of my knowledge. I have read and understand this office policies on Notice Of Privacy Practice, and Financial Insurance Filing Policies, and have been provied a copy if I request one. I understand my personal health information is important, will be protected , and will not be misused by Sanger Eye Care. If I have insurance benefits, I authorize payment and all medical and vision benefits on my behalf to Sanger Eye Care. I realize I am ultimately responsible for deductibles, co-payments, and service/product not covered by my insurance.

Patients Name Guardians Name Date

3D Imaging and Retina Photos Available

Sanger Eye Care offers state-of-the-art equipment to assist in identifying early eye disease of sight-threatening conditions. The Maestro takes both retina photography and 3-D imaging of the optic nerve and retina. This instrument is cutting-edge technology and helps us provide high-quality eye care, and offers invaluable peace of mind. We will take the photo and 3-D images as part of the preliminary testing. The fee for the doctor to review and interpret the photos, with you, is $25.

Yes, for $25, I would like the doctor to review and interpret the 3-D images taken of the retina, review the nerve fiber thickness, and discuss the photos taken.

No, I decline a 3-D assessment and interpretation of my retina.

Submit Form