Online Patient Form

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

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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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