Online Patient Form

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After completing all the forms, please submit your data on the final tab. Thank you!

Demographics


Patient Information
TitleFirstLastMISuffixNickname
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/GuardianDrivers License #



Insurance

Primary 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:
Secondary 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:
Tertiary 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


Reason for Visit:

Primary Care Physician: Last Visit:
Recent Tetanus Shot: Last Flu Shot:
Pregnant/Nursing?:

Injuries, Surgeries, Hospitalizations:

Systemic Medications:

Eye Medications:

Drug Allergies:

Pharmacy:
Over The Counter Meds:
Vitamins:

Do you have a history of the following medical conditions/symptoms?:
Do you have a history of the following eye conditions/symptoms?:
Are there any medical conditions that occur within your family?:

Review of Systems

General:
Ear/Nose/Throat:
Respiratory:
Genitourinary:
Musculoskeletal:
Skin:
Cardiovascular:
Psychiatric:
Endocrine:
Blood/Lymph:
Gastrointestinal:
Immune:

Social History

Hobbies:

Preferred Language:
Race:
Ethnicity:

Smoking Status: Type: How Long:
Alcohol: Type: How Long:

Submit Data

AUTHORIZATION FOR RELEASE OF IDENTIFYING HEATH INFORMATION ACKNOLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

ROBERT D. GILLETT, O.D.
418 W PUTNAM AVE
PORTERVILLE, CALIFORNIA 93257
559-784-4063

I authorize Robert D. Gillett, O.D. to release health information identifying me (including, if applicable, information about substance abuse, mental health conditions, and HIV infections or AIDS) under the following conditions.

I authorize Robert D. Gillett, O.D. to text to the cell phone number on file such things as appointment verification, eyewear pick-up times, and scheduling pf eye health and vision appointments.

It is completely your decision whether or not to sign this authorization form, We Will refuse to treat you if you choose not to sign this authorization. If You sign this authorization, you may revoke it at any time by contacting in writing, FAX or email to the Privacy Official noted in the Notice Of Privacy Practices.

When your health information is disclosed under this authorization, the recipient has no duty to protect its confidentiality, The recipient may re-disclose the information as he/she wishes.

The Law requires that Robert D. Gillett, O.D. make every effort to inform you of your rights related to your personal health information. By signing below, I acknowledge that:

I HAVE READ AND UNDERSTAND THIS FORM, BY CLICKING THE SUBMIT BUTTON BELOW, I AM VOLUNTARILY AGREEING TO ITS TERMS.