Online Patient Form

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

Patient Information


TitleFirst*Last*MISuffixNickname
Address:*
City: State/ZipCode
Cell Phone: Other Phone:
Email Preferred Contact Method:
SSN (Last 4) Employment Status
Birthday Employer/School Name
Sex Occupation
Marital Status Misc/Guardian

How did you hear about us?: Referral Name/Other:

Vision insurance

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:

Vision Insurance 2

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:

Medical insurance 1

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:

Medical Insurance 2

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:

History

Name: Date of Upcoming Eye Exam:
Name of Medical Doctor: Medical Dr.s Phone #:
Date of Last Eye Exam: Date of Last Medical Exam:

Lifestyle Index

Do you drive? Yes No       Do you have visual difficulty while driving? Yes No
Do you often get headaches? Yes No
Do you experience stiffness / tension in your neck / shoulders when you work on a computer? Yes No
Do your eyes tire, get red, or burn when workin on a computer for long hours? Yes No
Do your eyes get increasingly tired as the day goes on? Yes No
Do bright lights like vehicle headlights or florescent lights bother you? Yes No

Medical History

Do you have allergies to medications? Yes No

If yes, please list medications you are allergic to:


Do you take medications? Yes No

If yes, List any medications you take (including oral contraceptives, over the counter medications, vitamins, and supplements):


List all major injuries, surgeries, and/or hospitalizations you have had:


Are you pregnant and/or nursing? Yes No
Do you wear glasses? Yes No       If yes, how old is your present pair?
Do you wear contact lenses? Yes No       If yes, how old is your present pair?
Contact Lens Type:               Are they comfortable? Yes No

Family History:

Please note if you or any family members, living or deceased, have had any of the following conditions:

Lazy Eye         Macular Degeneration         High Blood Pressure        
Glaucoma Retinal Detachment Cataracts
Diabetes Blindness

Please explain any boxes that you have checked:

Review of Systems:

Please check the box if you had any repeated problems in the following areas:

CONSTITUTIONAL EYES
Fever Loss of Vision
Weight Loss/Gain Blurred Vision
INTEGUMENTARY (skin) Double Vision
Skin Cancer Dryness
NEUROLOGICAL Flashes / Floaters
Headaches   BLOOD / LYMPH
Parkinsons Disease Anemia
Seizures Bleeding Problems
EARS, NOSE, MOUTH HIV Positive
Allergies / Hay Fever MUSCLES / BONES / JOINTS
Dry Throat / Mouth Arthritis
CARDIOVASCULAR Connective Tissue Disease
High Blood Pressure PSYCHIATRIC
Heart Disease
RESPIRATORY
Asthma
Emphysema
GASTROINTESTINAL
Diarrhea
Constipation
Inflammatory Bowel Disease
   
ENDOCRINE
Diabetes
GENITOURIUARY
Genitals / Kidney / Bladder

If you selected any of the above conditions, or have a condition not listed, please explain:

I certify that I have filled out the above information to the best of my knowledge.
Patient Signature: Date:
Parent / Guardian Signature Date:

(if patient is under 18)

Financial Waiver and Release

The insurance information I, , provided on is true to the best of my knowledge. I agree to pay any co-payments, co-insurance, and deductibles as required by my insurance company for the goods and services provided. If for any reason my insurance company denies or considers any goods or services not covered under my plan, I understand that I will be financially responsible for the bill.

I authorize my insurance benefits to be paid directly to Montgomery Village Eye Center Inc. I also authorize Montgomery Village Eye Center Inc. to release any information required to my insurance company in order to process my claims.

I have read and understand the above statements.

Patient Signature: Date:

Parent / Guardian Signature: Date:
(If patient is under 18)

HIPAA PRIVACY POLICY

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I acknowledge that I have received a copy and agree to the offices HIPAA Policies.

Patient Signature: Date:

Parent / Guardian Signature: Date:

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