Online Patient Form
After completing all your information, please submit your data on the final tab. Thank you!
Demographics
Insurance Information
Medical History
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mrs.
Mr.
Ms.
Dr.
Address:
City:
State:
CA
TX
AL
AK
AZ
AR
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
Zip:
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer / School Name
Primary Doctor
No Doctor Assigned
Dr. Fisher, Jen
Dr. Kim, Susan
Dr. Laubach, Edward
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mrs.
Mr.
Ms.
Dr.
Address
City
State
ZipCode
CA
TX
AL
AK
AZ
AR
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:
Vision
Primary Vision Insurance
Insurance Name:
None
Aetna
Affinity Medical Group-Bay Valley Region
BC BS
BLUECROSS PPO-in network - Anthem Blue Cross
Blueshield -out of network - Blueshield
California Ophthalmic Laser Associates, Medical P.C.
Cigna
CVF
Eyeconic
EYEMED Access Only - Eyemed
Governmental Employee Health Association
HMO / Kaiser -out of Network
Logistics Health Incorporated
Medicare
MES - MES
MetLife (VSP Choice)
New Insurance
Optum Health (END 9/8/12) - OptumHealth
Other
Premera Blue Cross
Private Pay
Shared Eye Care / LASIK /COLA
SUPERIOR - Superior
UMR
United Health Care -out of network
VSP Advantage
VSP Choice - VSP Choice
VSP Elements
VSP Healthy Families
VSP Other
VSP Primary Eye Care
VSP Regional Network
VSP Signature - VSP Signature
VSP State of California
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 Vision Insurance
Insurance Name:
None
Aetna
Affinity Medical Group-Bay Valley Region
BC BS
BLUECROSS PPO-in network - Anthem Blue Cross
Blueshield -out of network - Blueshield
California Ophthalmic Laser Associates, Medical P.C.
Cigna
CVF
Eyeconic
EYEMED Access Only - Eyemed
Governmental Employee Health Association
HMO / Kaiser -out of Network
Logistics Health Incorporated
Medicare
MES - MES
MetLife (VSP Choice)
New Insurance
Optum Health (END 9/8/12) - OptumHealth
Other
Premera Blue Cross
Private Pay
Shared Eye Care / LASIK /COLA
SUPERIOR - Superior
UMR
United Health Care -out of network
VSP Advantage
VSP Choice - VSP Choice
VSP Elements
VSP Healthy Families
VSP Other
VSP Primary Eye Care
VSP Regional Network
VSP Signature - VSP Signature
VSP State of California
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 Information
Insurance Name:
None
Aetna
Affinity Medical Group-Bay Valley Region
BC BS
BLUECROSS PPO-in network - Anthem Blue Cross
Blueshield -out of network - Blueshield
California Ophthalmic Laser Associates, Medical P.C.
Cigna
CVF
Eyeconic
EYEMED Access Only - Eyemed
Governmental Employee Health Association
HMO / Kaiser -out of Network
Logistics Health Incorporated
Medicare
MES - MES
MetLife (VSP Choice)
New Insurance
Optum Health (END 9/8/12) - OptumHealth
Other
Premera Blue Cross
Private Pay
Shared Eye Care / LASIK /COLA
SUPERIOR - Superior
UMR
United Health Care -out of network
VSP Advantage
VSP Choice - VSP Choice
VSP Elements
VSP Healthy Families
VSP Other
VSP Primary Eye Care
VSP Regional Network
VSP Signature - VSP Signature
VSP State of California
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
Chief Complaint
Reason for Visit:
Location:
Both eyes
Right eye
Left eye
Other
Severity:
Mild
Moderate
Severe
Other
Quality:
no change
worse
better
constant
throbbing
slightly worse
a little better
much better
Vision is good
Other
Duration:
ongoing
1 day
2 days
3 days
4 days
5 days
6 days
1 week
1 month
3 months
6 months
1 year
Other
Timing:
Always
Sometimes
AM
PM
Other
Context:
computer
outside
reading
driving
tv
school
Other
Modifying:
Medication
Glasses help
Drops help
Contacts Help
Other
Associated:
dizzy
headache
loss of vision
blurred vision
eye pain
Other
Secondary Reasons:
Location:
Both eyes
Right eye
Left eye
Other
Severity:
Mild
Moderate
Severe
Other
Quality:
no change
worse
better
constant
throbbing
slightly worse
a little better
much better
Vision is good
Other
Duration:
ongoing
1 day
2 days
3 days
4 days
5 days
6 days
1 week
1 month
3 months
6 months
1 year
Other
Timing:
Always
Sometimes
AM
PM
Other
Context:
computer
outside
reading
driving
tv
school
Other
Modifying:
Medication
Glasses help
Drops help
Contacts Help
Other
Associated:
dizzy
headache
loss of vision
blurred vision
eye pain
Other
Review of Ocular System
Ocular History:
None
Itching
Burning, Stinging
Red
Floaters
Flashes Of Light
Eye Injuries
Eye Surgery
Amblyopia
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Other
Eye Meds:
None
Cromolyn NA 4%
Visine
Patanol
Xalatan
Travatan
rewetting drops
Elestat
Vigamox
Alphagan
Refresh
Theratears
Genteal
Pred Forte
Lotemax
Alrex
Systane
Blink
Other
Last Eye Exam:
1 year
2 years
3 years
Other
By Doctor:
Boyle
Cass
Doesn't Remember
Never
DeRouen
Maynard
Blount
Hyde
Doucet
Singla
Abbas
Harmon
Levacy
Diaz
Lehman
Chuckweike
Fracht
Conroy
Lens Crafters
EyeMart
EyeMasters
Pearl
Rising
Yu
Johnson
Broussard
Other
Primary Vision Correction:
None
Glasses-Full Time
Glasses-Readers Only
Contacts - Soft
RGPs
PMMA
OTC readers
Other
Back up glasses?
No
Yes
Other
Want new glasses?
Yes
No
Other
Fill out
only
if you have/had worn contacts.
Type of contacts worn in past:
None
Disposable
Conventional
Colored
RGP
PMMA
Cobalt Study Lens
Soft
Other
Wear Time:
>2 hours today
All day
Occ. Overnight
Extended
8 hours
10 hours
12 hours
Overnight
Other
Cleaner:
None
PureMoist
Optifree
Clear Care
Boston
Renu
Biotrue
Aquify
Other
Disposal:
daily
2 weeks
monthly
weekly
yearly
Other
Days per Week Worn:
Hours comfortably worn:
Family Ocular History
Macular Degeneration:
No
Parents
Siblings
Grandparent
Other
Glaucoma:
No
Parents
Sibling
Grandparent
Other
Retinal Detachment:
No
Parents
Siblings
Grandparent
Other
Cataracts:
No
Parents
Siblings
Grandparent
Other
Crossed / Lazy Eyes:
No
Parents
Siblings
Grandparent
Other
Review of Systems
General:
None
Negative
Other
Ear/Nose/Throat:
None
Allergies
Sinus Problems
Chronic Cough
Dry Throat / Mouth
Hard of Hearing
Dizziness
Ringing in Ears
Other
Cardiovascular:
None
Vascular Disease
HBP
Heart Surgery
Other
Genital/Kidney/Bladder:
None
painful urination
frequent urination
impotence
yellow jaundice
Other
Respiratory:
None
Asthma
Bronchitis
Emphysema
COPD
Other
Muscles/Bones/Joints:
None
joint pain
stiffness
swelling
cramps
arthritis
Other
Skin:
None
pimples, warts
growths
rash
Other
Blood/Lymph:
None
bleeding
cholestrolemia
anemia
Other
Psychiatric:
None
anxiety
depression
insomnia
Other
Gastrointestinal:
None
Diarrhea
Constipation
Ulcer
Acid Reflux
Other
Endocrine:
None
diabetes
hypothyroid
hyperthoyroid
Other
Allergic/Immunologic:
None
sneezing
swelling
redness
itching
hives
lupus
Other
Neurological:
None
numbness, paralysis
headache
seizures
migraines
Other
Medical History
Primary Care Physician:
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
Other
Reason For Visit:
Check up
Annual
Specific
Other
Over The Counter Medications:
None
Asprin
Acetomenophin
Ibuprofen
Other
Vitamins:
None
A
E
C
Zinc
Xanten
Lutein
Other
Pregnant Or Nursing:
No
Yes
Unsure
Other
Recent Tetanus Shot:
Yes
No
Other
Injuries, Surgeries, Hospitalizations:
Family Medical History
Please describe your family medical history.
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Other
Submit Data
Back to top
Home
About Us
Doctors
Staff
Vision Therapy
Vision Therapy Testimonials
Undetected Vision Problems
Vision Care & Products
Lenses and Frames
Contacts
Vision Correction
Eye Conditions
Eye Diseases
Vision Problems
Promotions
Patients
Insurance Information
Patient Forms
Patient Reviews
Contact