Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	TX AL AK AZ AR CA 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:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Date Of Birth:		Age:
Sex	Male Female	Prefered Pronouns	He/Him She/Her They/Them Other
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Occupation		Misc/Guardian
Employment Status	Employed Full-Time Student Part-Time Student

Preferred Language:

Race:

Ethnicity:

Whom may we thank for referring you to us?

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

City	State	ZipCode
	TX AL AK AZ AR CA 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:

Primary

Insurance Information

Insurance Name:	None AARP Aetna Bankers Blue Cross Blue Shield Blue Cross Blue Shield of ND California Water Service Co Carpenters Trust of Western WA; 1st Choice Cigna CNIC Health Solutions Community Health Network of WA Dept of Social & Health Services First Choice Health GEHA Group Health Health Comp Health Partners HMA - Healthcare Management Administrators Humana Claims Office Kaiser Permanente Kitsap Physicians Services Mail Handlers Medicare Meritan Health MetLife Mutual of Omaha National Automatic Sprinkler Industry Northwest Benefit Network Northwest Sheet Metal Workers NW Administrators NW Roofers ODS Operating Engineers; First Choice Pers Care Premera Blue Cross Premera Life Wise Puget Sound Electrical Workers Regence Blue Shield Regence Blue Shield Federal Regence Blue Shield; Boeing Traditional Med Plan Retiree Trust Seattle Area Plumbing & Pipefitting Seattle Firefighters Trust Security Life Select Account Sound Health & Wellness Trust Stonebridge Life Insurance Co. Teamsters The ODS Company The Painters Trust Tricare Trusteed Plans Service Corp Uniform Medical Plan United American United Health Care USAA Life Insurance Vision Service Plan WA Bakers Trust
Insurance Plan:
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

Insurance Information

Insurance Name:	None AARP Aetna Bankers Blue Cross Blue Shield Blue Cross Blue Shield of ND California Water Service Co Carpenters Trust of Western WA; 1st Choice Cigna CNIC Health Solutions Community Health Network of WA Dept of Social & Health Services First Choice Health GEHA Group Health Health Comp Health Partners HMA - Healthcare Management Administrators Humana Claims Office Kaiser Permanente Kitsap Physicians Services Mail Handlers Medicare Meritan Health MetLife Mutual of Omaha National Automatic Sprinkler Industry Northwest Benefit Network Northwest Sheet Metal Workers NW Administrators NW Roofers ODS Operating Engineers; First Choice Pers Care Premera Blue Cross Premera Life Wise Puget Sound Electrical Workers Regence Blue Shield Regence Blue Shield Federal Regence Blue Shield; Boeing Traditional Med Plan Retiree Trust Seattle Area Plumbing & Pipefitting Seattle Firefighters Trust Security Life Select Account Sound Health & Wellness Trust Stonebridge Life Insurance Co. Teamsters The ODS Company The Painters Trust Tricare Trusteed Plans Service Corp Uniform Medical Plan United American United Health Care USAA Life Insurance Vision Service Plan WA Bakers Trust
Insurance Plan:
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 AARP Aetna Bankers Blue Cross Blue Shield Blue Cross Blue Shield of ND California Water Service Co Carpenters Trust of Western WA; 1st Choice Cigna CNIC Health Solutions Community Health Network of WA Dept of Social & Health Services First Choice Health GEHA Group Health Health Comp Health Partners HMA - Healthcare Management Administrators Humana Claims Office Kaiser Permanente Kitsap Physicians Services Mail Handlers Medicare Meritan Health MetLife Mutual of Omaha National Automatic Sprinkler Industry Northwest Benefit Network Northwest Sheet Metal Workers NW Administrators NW Roofers ODS Operating Engineers; First Choice Pers Care Premera Blue Cross Premera Life Wise Puget Sound Electrical Workers Regence Blue Shield Regence Blue Shield Federal Regence Blue Shield; Boeing Traditional Med Plan Retiree Trust Seattle Area Plumbing & Pipefitting Seattle Firefighters Trust Security Life Select Account Sound Health & Wellness Trust Stonebridge Life Insurance Co. Teamsters The ODS Company The Painters Trust Tricare Trusteed Plans Service Corp Uniform Medical Plan United American United Health Care USAA Life Insurance Vision Service Plan WA Bakers Trust
Insurance Plan:
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

Please type your answers or choose from the selected drop downs. If your answer is not available as a drop down, please select 'Other' to type in your answer. Thank you!

Date of Last Eye Exam:

Doctor's/ Clinic Name:

Are you Interested in Contact Lenses?:	Yes	No
Have you ever worn Contact Lenses?:	Yes	No

Contact Lens Wearers: Are your lenses comfortable? Yes No     Current Brand:

What solution do you use?

What is your replacement schedule?

Daily Weekly Every 2 weeks Monthly Quarterly Yearly Other

How old is your current pair?

Social History

	Yes	No
Do you use tobacco products?			If yes, type/amount/how often:
Do you drink alcohol?			If yes, type/amount/how often:
Do you use illegal drugs?			If yes, type/amount/how often:

Are you currently or have you ever been infected with:

	Yes	No
Tuberculosis
Hepatitis
HIV
Syphilis
Chlamydia

Eye History

Do you have experience any of the following?

	Yes	No
Blurred Vision
Burning
Eyes Feel Dry
Double Vision
Eyes Tear
Eyes "Hurt/Tired"
Flashes
Floaters
Foreign Body Sensation
Eyes Itch
Bothered by Light
Halos around Lights
Redness
Gritty/Sandy Eyes
Mucous Discharge

Do you have a history of any of the following?

	Yes	No
Blindness
Eye Turn
Lazy Eye
Patching
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Eye Surgery
Eye Injury

Medical History/Review of Systems

Primary Care Physician:

Last Visit:

Height:

Weight:

Do you have any allergies to medications? Yes No     If yes, please list:
Are you pregnant or nursing? Yes No N/A

Do you currently, or have you ever had, any problems in the following areas?

1- CONSTITUTIONAL	Yes     No
Fever
Weight Loss/Gain
Other
2- SKIN
Shingles
Eczema
Rosacea
Other
3- NEUROLOGICAL
Migraines
Seizures
Multiple Sclerosis
Other
4- ENDOCRINE
Thyroid Problems
Diabetes
Other
5- ALLERGY/IMMUNE
Drug Allergy
Environmental Allergy
Lupus
Other
6- RESPIRATORY
Asthma
Bronchitis
Emphysema
Other
7- EAR/NOSE/THROAT
Allergy/Hay Fever
Chronic Cough
Sinus Congestion
Other

 

8- CARDIOVASCULAR	Yes     No
Heart Disease
High BP
Stroke
Vascular Disease
Other
9- GASTROINTESTINAL
Crohn's
Colitis
Ulcer
Other
10- GENITOURINARY
Genital/Kidney/Bladder
Other
11- MUSCULOSKELETAL
Arthritis
Fibromyalgia
Muscular Dystrophy
Other
12- BLOOD/LYMPH
Anemia
Leukemia
Bleeding Problems
Other
13- PSYCHIATRIC
Depression
Panic Disorder
Schizophrenia
Other

List of your current medications:

Family History Family history is unknown/adopted

Any history of the following in any family members (parents, grandparents, siblings, children)?

	Yes	No	Relationship to Patient
Lazy Eye
Blindness
Cataracts
Glaucoma

	Yes	No	Relationship to Patient
Retinal Detachment
Macular Degeneration
High Blood Pressure
Diabetes

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Dependents covered by acknowledgement:

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We do require a 24 hour notice if you are unable to keep your appointment.
A $50 cancellation/no show fee may be applied for missed appointments

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