Online Patient Form

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Demographics


Patient Information
Title First Last MI Suffix Nickname Pronoun
Address:
City: State/ZipCode



Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian
Title First Last MI Suffix

Address

City State ZipCode
Home Phone:
Work Phone:

Primary-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:

Second Med

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:

Third Med

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 Plan

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:

2nd 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:

Medical History

Briefly describe the main reason for having an examination today:
Associated: Do you have any other symptoms related to this?
Other eye issues or problems
Full-time Part-time
If part-time, how often/when?
Full-time Part-time
If part-time, how often/when?
Soft Rigid Gas PermeableYesNo
Current Brand:
What solution do you use?
What is your replacement schedule?
How old is your current pair?
Please list all eyedrops you use (OTC and Rx):
How often used?:
Blindness Eye Turn Lazy Eye Keratoconus Macular Degeneration Retinal Detachment Glaucoma Cataracts Headaches Blurred Vision Double Vision Eyes "hurt or tired" Halos around lights Bothered by light/sun Frequent Styes Eyes frequently red Eyes itch Eyes Burn Eyes tear Eyes feel dry Eyes feel sandy/gritty Flashing Lights Floaters
Other eye disease or condition
Describe any eye injuries:
List any eye surgeries:
How many hours a day do you use a computer?
Describe any visual symptoms from computer use:
Are you pregnant or nursing? Yes No If yes, what is the due/birth date?
Allergies/Hay fever Multiple Sclerosis Diabetes Thyroid problems Arthritis Migraines Asthma Emphysema High blood pressure Stroke Anemia Cancer
Notes:
BMI
Weight
Physician's Name:
Last Visit Date:
>
How often do you consume alcohol:
Hepatitis HIVSTDs
Who referred you to our office?
If not referred, how did you hear about The Eyecare Center?
Does your family have a history of these diseases?
Poor Vision
Blindness
Eye turn
Lazy Eye
Glaucoma
Cataracts
Cancer
Diabetes
High Blood Pressure
Stroke
Thyroid
Other Inherited Disease
Macular Degeneration
Retinal Detachment/Disease
Date
Occupation:
Employer:
Counseled pt on not smokingFamily history is unknown/adopted
How often do you smoke/use tobacco products?

Signatures/Submit Data


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I have read and agree to the above policy:
Patients E-Signature: Date:

Click here for Patient Responsibility

Optomap Retinal Exam:
Our doctors highly recommend that you have an Optomap Retinal Exam. The Optomap is a comprehensive method of evaluating, monitoring, and helping treat various eye conditions.
There will be a $30.00 charge for this service that insurance will not cover.

Yes, Optomap approved

Not sure, need to discuss.

I have read and agree to the above policy:

Patients E-Signature: Date: