New Patient Form

Demographics

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:		Email
Work Phone:		SSN
Cell Phone:		Birthday
Contact Method:	Home Phone Work Phone Cell Phone Text Message Email	Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Referred By:	Dallas Eye Associate DARS Facebook Family Friends Google Search Insurance Search Postcard Walk-In Walmart/Sam's Club previous patient Yelp Other	Referring Person Name:
Primary Dr	No Doctor Assigned Dr. Arora, Rajan	Allergies:	Food Allergy Drug Allergy Latex Allergy

Billing Information

Is The Billing Address Different?

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 MEDICAL INSURANCE

Insurance Information

Insurance Name:	None Aetna All Savers Blue Cross Blue Shield Cigna DARS GPA HealthSmart HealthSpring Humana Medicare Meritain Health Ins PHCS Scott & White Medical Insurance Co. UMR United Healthcare United Healthcare Golden Rule Wellcare Wellmed Networks Inc
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:

VISION INSURANCE

Insurance Information

Insurance Name:	None Always Care Avesis Cigna DARS Davis Vision Envolve Vision EyeMed Guardian Humana NVA Spectera/Optum Health Superior Vision Superior Vision Medicaid/Medicare Plan United Healthcare Vision Service Plan
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

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician?

Physicians Phone #:

Are you pregnant/nursing?

No Unsure Pregnant Nursing Other

Do you drink alcohol?

None occasional social 1-2 drinks/day several drinks/day Other

Do you smoke?

Current every day smoker Current some day smoker Former smoker Never smoker Unknown Other

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Any history of injuries/surgeries?

None car accident broken arm broken leg head trauma herniated discs hip replacement knee replacement knee surgery shoulder surgery tonsillectomy ear tubes sinus surgery appendectomy hernia repair gastric by-pass lap band hemorrhoidectomy cholecystectomy prostatectomy mastectomy C-section D&C hysterectomy ovariectomy coronary stent coronary bypass pacemaker pacemaker/defribrillator heart valve repair aneurism Other

Any history of eye injuries/surgeries?

None Anti-VEGF tx blepharoplasty corneal transplant cryo ECCE/IOL filtering procedure focal laser grid laser laser trabeculoplasty LASIK LPI peripheral retinal laser PRK PRK PRP ptosis repair RD repair RK scleral buckle SLT strab sx stromal puncture valve YAG cap Other

Please list all prescription and over-the-counter medications you take and for what conditions:

Please list all drug allergies you have:

General Problems:	Good Fever Fatigue Loss of Appetite Weight Gain Weight Loss Other	(Chronic fever, unexpected weight loss/gain, fatigue)
Ear/Nose/Throat:	None Chronic Cough Congestion Daytime Drowsiness Dry Mouth/Throat Gasp While Sleeping Headache Hearing Problems Heavy Snoring Morning Headaches Runny Nose Sinus Problems Sleep Apnea Toothache Other	(Hearing loss, sinus problems, sore throat)
Heart Problems:	None Chest Pain Racing Heartbeat Shortness of Breath Swollen Feet/Ankles TIAs Other	(Chest pain, irregular heart beat, cold hands/feet)
Respiratory:	None Chronic Cough Cyanosis Productive Cough Shortness of Breath Wheezing Other	(Shortness of breath, wheezing, coughing)
Gastrointestinal:	None Bloody Stools Bronzing of Skin Constipation Dark Urine Diarrhea Gastric Reflux (GERD) Jaundice Nausea Vomiting Other	(Heartburn, abdominal pain, vomiting)
Genitourinary:	None Overactive Bladder Painful Urination Underactive Bladder Urgency in Urination Urinary Incontinence Other	(Painful urination, blood in urine, sex organ problems)
Musculoskeletal:	None Decreased Range of Motion Joint Pain Muscle Cramps Pain/Tenderness Stiffness Swelling Weakness Other	(Muscle aches, joint pain, swollen joints)
Skin Problems:	None Acne Blisters Cysts Dandruff Eczema Erythema Growths Nodules Psoriasis Rash Scales Seborrheic/Actinic Keratosis Ulcerations Warts Other	(Rashes, excessive dryness, growths/lumps)
Neurological:	None Balance Problems Dementia Memory Problems Muscle Weakness Numbness Speech Problems Tremors Vertigo Tingling Personality Changes Other	(Numbness, weakness, headaches, blackouts)
Psychiatric:	None Anxiety Changes in Eating Habits Changes in Sex Drive Compulsive Delusions Depression Excess Anger Excessive Worrying Frequent Mood Changes Hallucinations Insomnia Obsessive Paranoia Social Withdrawal Substance Abuse Suicidal Violence Other	(Depression, anxiety, hallucinations, insomnia)
Endocrine:	None Change in Appetite Cold Intolerance Excess Thirst Frequent Urination Hair Loss Heat Intolerance Hypothyroid Increased Sweating Other	(Change in appetite, excess thirst, hair loss)
Blood/Lymph:	None Bleeding Bleeding Gums Cuts Slow to Clot Easy Bruising Heavy Periods Hx of Significant Blood Loss Jaundice Nosebleeds Pale Skin Pounding in Ears Rapid Hearbeat Shortness of Breath Other	(Bruising, weakness, unusual paleness, swollen glands)
Immune Problems:	None Asthma Hives Itching Mild Allergy Symptoms Redness Severe Allergy Symptoms Sneezing Swelling Other	(Frequent infections, allergic reactions to foods, dust)

Submit Data / Patient Signatures

NOTICE OF PRIVACY PRACTICES AND CONSENT FORM

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACESS TO THIS INFORMATION; WHEREAS THE "OFFICE" PERTAINS TO "VISION ARORA." PLEASE REVIEW IT CAREFULLY.

The office is required by law to maintain the privacy of your health, to follow the items of this notice, and to provide you with this notice of its legal duties and privacy practices with respect to your health information. We will not use or disclose medical information about you without your written authorization, except as described in this NOTICE.

USES AND DISCLOSURES OF HEALTHCARE INFORMATION

The Office protects the privacy of your health information. The law permits the Office to use your health information for the following purposes:

• Treatment, Payment, and Regular Health Care Operations - Information obtained by the Office will be used to dispense and provide prescription ophthalmic goods and services to you, bill your insurance carrier if you have third party coverage, and to record and monitor the service provided to you. Information will also be provided to you upon your request.

• As and When Required by Law - We may use and disclose your health information to Public Health Officials, Health Oversight Activities (For audits, investigations, etc.), Judicial and Administrative, Deceased Person Information, Worker Compensation Programs, Food and Drug Administration (FDA for reporting of adverse drug events and quality issues), if there is a serious threat to your health or safety, in times of National Security, if you are in the Military or a Veteran of the armed forces when requested, or if you become an inmate in a correctional facility.

• Personal Communications - We may contact you to provide appointment reminders, annual eye examination recalls and other information about treatment alternatives or other health-related benefits and services that may be of interest to you as well as communicate with individuals involved in your care or payment for your care.

• Disclosure to Our Business Associates - There are some services provided by us through contracts with business associates. When these services are contacted for, we may disclose health information about you to our business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, we require the business associated to appropriately safeguard the health information.

• Victims of Abuse, Neglect, or Domestic Violence - We may disclose your health to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.

• Appointment Reminders - Because we believe regular care is very important to your general health, we will remind you of a scheduled appointment, or that it is time to contact us for an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may interest you or a family member. This may include postcard, folding cards, letters, telephone, voice mail, text messages, and/or e-mails.

• Marketing Communications. We must obtain your written authorization prior to using your health information to send you any marketing materials. We may communicate with you about products or services relating to your treatment, care, or alternative treatments, or new providers.

WHEN THE OFFICE MAY NOT USE OR DISCLOSE YOUR HEALTH INFORMATION

Except as described in this Notice of Privacy Practice, the Office will not use or disclose your health information without your written authorization. If our state law provides additional restrictions upon any of the forgoing uses and disclosures, we must follow our state law of Texas.

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

• You have the right to request restrictions on certain uses and disclosures of your health information. The Office reserves the right to agree/disagree to your request.

• You have the right to inspect and copy your health information as long as the Office maintains the health information. Your health information usually will include prescription and billing records. To inspect or copy your health information, you must submit a request in writing to the location that provided your services. We may charge you a fee for the cost of copying, mailing, or other supplies that are necessary to grant your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. You have the right to request that the Office amend your health information that is incorrect or incomplete. The office is not required to change your health information and will provide you with information about the procedure for addressing any disagreement with the denial.

• You have the right to receive an accounting of disclosures of your health information for most purposes other than treatment, payment, health care operations provided to you, and certain government functions. You must specify the time period but be no longer than six years. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.

• You may request communications of your health information by alternative means or at alternative locations. For example, you may request that we contact you about medical matters or at a different residence or post office box. Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests.

CHANGES TO THIS NOTICE OF PRIVACY PRACTICE

The Office reserves the right to amend our practices and this Notice of Privacy Practices at any time in the future and to make the new Notice effective for all medical information we maintain. Until such amendment is made, the Office is required by law to comply with this Notice.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions or would like additional information about the Office' s Privacy Practices, you may contact the Office. If you believe your privacy rights have been violated, you may file a written complaint, for which there will be no retaliation.

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I have received and reviewed a copy of Vision Arora' s Notice of Privacy Practices.

Signature: Date:

CONTACT LENS QUESTIONNAIRE:

1. Do you currently wear contact lenses?
Yes No If No, please skip this section.

2. What type of contact lenses are your currently wearing?
Rigid Soft

3. If you are wearing soft contact lenses what is your current modality of wear?
Daily disposable 2week disposable Monthly disposable Quarterly replacement Other

4. How old is your current pair of contact lenses?


5. Are you satisfied with the vision and comfort of your current pair of contact lenses?
Yes No

6. Would you like to:
Continue with what you have Change to:

7. Do you prefer clear or colored contact lenses?
Clear Colored Both

8. Please check all that apply to your contact lenses:
Feel less comfortable in the afternoon Feel painful after insertion Are not as clear as I would like Feel irritated and/or eyes become red after wearing for a few hours

9. Please describe any concerns you have with your contact lenses:


What is a contact lens fit?

A contact lens fitting is an additional, separate portion of a comprehensive eye examination. As contact lenses are most often an elective addition to a glasses prescription, most insurance companies do not cover contact lens fits. Any contact lens fitting fees that are not covered by insurance will be the responsibility of the patient. At Vision Arora, our contact lens fit fees range from $95 to $250 depending on the type of contact lens being fit. The contact lens fitting fee pays for the initial fitting and 2 follow ups visits within 30 days. Contact lens fits do not include the actual supply of contact lenses. Contact lens prescriptions expire after 1 year. Any concerns requiring a refitting or power adjustment for your contact lenses after 30 days from your exam date while be charged after the grace period is over.

What is included in a contact lens fit?

• Determination of candidacy for contact lens wear
• Determination of contact lens prescription based on glasses prescription
• Evaluation of tear film and cornea
• Evaluation of contacts on the eye
• Topographical analysis of cornea if necessary
• Insertion/removal training for first time wearers
• Contact lens trials until determination of final prescription
• Travel size contact lens solution and case

I have read and agree to the terms of the Contact Lens Fit Agreement.

Patient Signature: Date:

Please click on the below link to fill out the Lifestyle Index Form. Once completed close the window and press the Submit Button Below

Lifestyle Index Form