Online Patient Form
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Demographics
Patient Information
Title
First
Last
MI
Suffix
Nickname
Pronoun
Mr.
Mrs.
Ms.
Dr.
Rev.
he/him/his
she/her/hers
they/them/theirs
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
Cell Phone:
Home Phone:
Work Phone:
Last 4 numbers of SSN
Email
Date of Birth
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Married
Not Married
Employer / School Name
Guardian
Is the Billing Address Different?
Billing Information
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Copy Address From Above
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:
Primary
Insurance Information
Insurance Name:
None
Aetna
Anthem Blue Cross
Apostrophe
Avesis
Blue Cross Blue Shield
CARE IMPROVEMENT PLUS OF TEXAS INSURANCE COMPANY
Cigna
Davis Vision
Eyemed Vision Care
Gravie Administrative Services
Groupon
Humana
Lions Club
Medicare TX
NVA - National Vision Administrators LLC
Other
Spectera Eyecare Networks
Superior Vision
TML Health Plan
Tricare - East
Tricare - West
UMR
UNION PACIFIC RAILROAD EMPLOYES HEALTH SYSTEMS
United Healthcare
VBA
VSP
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
Insurance Information
Insurance Name:
None
Aetna
Anthem Blue Cross
Apostrophe
Avesis
Blue Cross Blue Shield
CARE IMPROVEMENT PLUS OF TEXAS INSURANCE COMPANY
Cigna
Davis Vision
Eyemed Vision Care
Gravie Administrative Services
Groupon
Humana
Lions Club
Medicare TX
NVA - National Vision Administrators LLC
Other
Spectera Eyecare Networks
Superior Vision
TML Health Plan
Tricare - East
Tricare - West
UMR
UNION PACIFIC RAILROAD EMPLOYES HEALTH SYSTEMS
United Healthcare
VBA
VSP
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:
Tertiary
Insurance Information
Insurance Name:
None
Aetna
Anthem Blue Cross
Apostrophe
Avesis
Blue Cross Blue Shield
CARE IMPROVEMENT PLUS OF TEXAS INSURANCE COMPANY
Cigna
Davis Vision
Eyemed Vision Care
Gravie Administrative Services
Groupon
Humana
Lions Club
Medicare TX
NVA - National Vision Administrators LLC
Other
Spectera Eyecare Networks
Superior Vision
TML Health Plan
Tricare - East
Tricare - West
UMR
UNION PACIFIC RAILROAD EMPLOYES HEALTH SYSTEMS
United Healthcare
VBA
VSP
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
Referred By:
Friend/Family
Previous
Walk In
Insurance
Advertisement
Internet
Other
Last Eye Doctor:
Moulder
Hughes
Soltys
Doesn't Remember
Other
Last Eye Examination:
Never
1 year
2 years
3 years
Over 5 years
Over 10 years
Other
Occupation:
Primary Care Physician:
Last Visit:
1 year
1 week
1 month
6 months
2 years or more
Other
Medical History
Family History of Eye Disease
Pregnant/Nursing:
Yes
No
Other
History of Eye Surgery
Ocular History
Do you smoke?
No
Former
Occasional
Everyday
Other
Do you drink alcohol?
No
Social
1-3x/week
>3x/week
Other
History of Eye Injury
Family Medical History
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