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:

Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:



Vision Insurance

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:

Medical Insurance

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 Medical Insurance

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:

Medical 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:


Social History

Do you drive? Yes No       Do you have visual difficulty while driving? Yes No
Do you use a computer? Yes No       How often?
Do you use tobacco products? Yes No If yes, type/frequency?
Do you drink alcohol? Yes No If yes, how much?
Do you use illegal drugs? Yes No If yes, type/frequency?
Have you ever been exposed to or infected with: Gonorrhea    Hepatitis    HIV    Syphilis    Herpes   

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) Chronic Infection
Skin Cancer Distorted Vision
NEUROLOGICAL Loss of Side Vision
Headaches Double Vision
Parkinsons Disease Dryness
Seizures Mucous Discharge
EARS, NOSE, MOUTH Redness
Allergies / Hay Fever Sandy or Gritty Feeling
Dry Throat / Mouth Itching
CARDIOVASCULAR Burning
High Blood Pressure Watery Eyes
Heart Disease Light Sensitivity
RESPIRATORY Eye Pain
Asthma Flashes / Floaters
Emphysema Tired Eyes
GASTROINTESTINAL Styes
Diarrhea BLOOD / LYMPH
Constipation Anemia
Inflammatory Bowel Disease Bleeding Problems
ENDOCRINE MUSCLES / BONES / JOINTS
Diabetes Arthritis
GENITOURIUARY Connective Tissue Disease
Genitals / Kidney / Bladder PSYCHIATRIC

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:

After Completing All Forms Submit Data on Final Tab