Online Patient Form

Demographics

First MI Last Suffix Nickname

Address:
City:		State/ZipCode	FL

Cell Phone:		Home Phone:
Other Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Marital Status	Single Married Separated Divorced Widowed Unknown
Employer/School Name		Primary Doctor	No Doctor Assigned Dr. Garmizo, O.D., FAAO, Gustavo Dr. Rhue O.D., FAAO, Brianna
Misc/Guardian

Is The Billing Address Different?

Vision Insurance

Insurance Information

Insurance Name:	None 1199SEIU National Benefit Fund AARP AARP MEDICARE COMPLETE ACCORDIA NATIONAL Administrative Concepts Inc AEQUICAPS AETNA LIFE AND CASUALTY ALICARE ALL STATE Am AMALGAMATED LIFE Ambetter AmeriBen AMERICAN MEDICAL SECURITY AMERICAN PIONEER LIFE American Public Life Amerigroup AMERISYS Anchor Benefit Consulting APWU HEALTH PLAN Assurant Health AUSA LIFE INSURANCE COMP, INC Auto Owners Insurance AVESIS Avmed B'NAI-B'RITH BANK OF AMERICA TRUST FUND BANKERS LIFE & CASUALTY BC BS FLORIDA BEECH STREET-MEDICAL BENEFIT MANAGEMENT COMPANY BENESIGHT Best Choice BRISTOL/CONNECTICUT GENERAL CARECREDIT/GEMB CBCA ADMINISTRATORS, INC. CELTIC CENTRAL STATE HEALTH/LIFE COMP CHAMPUS-PALMETTO GBA Cherokee Insurance Company CIGNA HEALTHCARE-TN CITY OF MARGATE City of North Lauderdale Coast to Coast Vision Disc Plan Colonial Penn Life Ins Comp Complete Benefits Solutions CONNECTICUT GENERAL LIFE INS CONSECO SENIOR HEALTH CO CONSTUTION STATE SERVICES, LLC CONTINENTAL GENERAL INSURANCE CO. CORESOURCE CORIS USA Correct Vision Corvel Corporation Coventry Health Care CREATIVE COLLECTION SERVICE DAVIS VISION Davis Vision Discount Plan Devoted Health Claims DIRECT ASSIGNMENT BENEFIT PLANS, INC DIVISION OF BLIND SERVICES DMERC Dr Contact Lens Dr. Contact Lens Emblem Health EMPIRE BC/BS NY EMPLOYEES BENEFIT ASSOCIATION EMPLOYERS MUTUAL, INC. EYEMED VDT EYEMED VISION CARE EYEMED VISION DISCOUNT PLAN F H P FEDAERAL HOME LIFE INSURANCE CO Federated Mutual Insurance FIRST HEALTH FIRST NATIONAL LIFE INS CO FIRST UNION FIRST UNITED AMERICAN LIFE INS FISERV HEALTH FLEI FLORIDA RETAIL FEDERATION FORTIS INSURANCE COMPANY Freedom Life GALLAGHER BENEFITS ADMIN GEHA GENERAL AMERICAN INSURANCE Gerber Life Insurance Company Globe Life GOLDEN RULE INSURANCE CO. GREAT-WEST HEALTHCARE GREAT-WEST HEALTHCARE GROUP & PENSION ADMIN, INC. GROUP HEALTH INS Guaranteed Trust Life GUARDIAN INSURANCE Hartford HEALTH ADVANTAGE PLAN HEALTH AND WELFARE FUND HEALTH COMP INSURANCE Health Equity Health Partners HEALTH PLAN OF AMERICA Health Scope Health Sun Healthnet Patient Centered Community Care Heritage Vision Plan HRM CLAIM MANAGEMENT, INC. HSA ACCT HUMANA INS CO IBEW Impact Health Sharing INDECS INDEPENDENT HEALTH INSURANCE CENTER Integra KANAWHA INSURANCE COMPANY LAWYERS LION'S CLUB MagnaCare MAIL HANDLERS BENEFIT PLAN MCS Plaza MEBA MEDICAL PLAN MEDICA INSURANCE COMPANY MEDICAID CONSULTEC MEDICAL BENEFIT ADMIN MEDICAL MUTUAL Medicare Part B Claims Medico Insurance Company Memorial Managed Care Plan Meritain Health Insurance METROPOLITIAN CASULATY INS MILLENNIUM LASER EYE CENTER MMA MMM of Florida Monumental Life Insurance Co MOTOROLA CLAIM SERVICES MSK GROUP MSLA Mutual Health Services MUTUAL OF OMAHA MUTUAL PROTECTIVE INS CO MVP Insurance Nassau Life Insurance NAT ASSOC OF LETTER CARRIERS NATIONAL EMPLOYEES HEALTH PLAN NATIONAL STATES OXFORD PLAN NATIONAL VISION ADMINISTRATORS Nationwide NEIGHBORHOOD HEALTH PLAN NEW ERA LIFE INS CO NEW YORK LIFE NEW YORK STATE BENEFIT NORTH SHORE HEALTH SYSTEM NY CARPENTERS WELFARE FUND NY ST CLAIMS/UNITED HEALTHCARE ophthalmology consultants OPTACOMP OPTI CHOICE OPTICARE MANAGED VISION Oscar Health Plan Inc. OUT OF NETWORK OXFORD HEALTH INSURANCE, INC. PAN AMERICAN LIFE INS PERFORMAX PHYSICIAN'S MUTUAL INSURANCE PMA Companies POE & BROWN POMCO Pop Healthcare POSTMASTER BENEFIT PLAN Preferred Care Partners PREVINTER PRIMARY PLUS PRINCIPAL HEALTH CARE PRINCIPAL LIFE INSURANCE COMP PRIORITY HEALTH PRIVATE PRIVATE HEALTH CARE SYSTEMS PROGRESSIVE AMERICAN INSURANCE PROVIDENT LIFE AND ACCIDENT RAILROAD MEDICARE Rand Eye Institute RPS Samba Health Benefit Plan SANUS HEALTH CORPORATION Security Life SEDGWICK CLAIMS MANAGEMENT Seminole Tribe of Florida Health Plan SHASTA ADMINISTRATIVE SERVICES Sheet Metal Workers Wraparound Plus Sightbox Sightrust Eye Institute PA Simply Healthcare Sisco Solis Solstice Source Access, Inc. SOUTHCARE PPO Special Insurance Service SPECTERA Staar Study Standard Insurance Company STANDARD LIFE INSURANCE STAR ADMINISTRATIVE SERVICES STATE FARM INSURANCE COMPANIES STEAMFITTERS LOCAL 439 HEALTH & WELFARE STIRLING & STIRLING, INC. Stonebridge Life Insurance Company Sunshine State Health Plan SUPERIOR VISION PLAN The Empire Plan THE GUARDIAN LIFE INS COMPANY The Loomis Company THE MAIL HANDLERS BENEFIT PLAN THE ULLICO FAMILY OF COMPANIES THE ZENITH COMPANY TLC TOWER LIFE INS COMP/T.L. BLDG transamerica life ins co TRICARE EAST Triwest UFT WELFARE FUND UMR UNICARE UNICARE STATE INDEMNITY PLAN UNION FIDELITY LIFE INSURANCE UNISYS UNITED AMERICAN INS UNITED FOOD & COMMERCIAL WRKER UNITED HEALTHCARE UNITED TEACHER ASSOCIATES INS. CO. UNIVERA UNIVERSAL HEALTHCARE INC. UNUM USAA LIFE INS COMP ATTN CLAIMS USIA/JONES & MERCER EMP BEN VA -US Dept of Veteran Affairs VCI VISION BENEFITS OF AMERICA VISION QUEST-FLORIDA VSP VSP-MEDICAL VSP-VDT WARD NORTH AMERICA WAUSAU BENEFITS INSURANCE Wells Fargo Bank, NA Zurich
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary On Account

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

Insurance Information

Insurance Name:	None 1199SEIU National Benefit Fund AARP AARP MEDICARE COMPLETE ACCORDIA NATIONAL Administrative Concepts Inc AEQUICAPS AETNA LIFE AND CASUALTY ALICARE ALL STATE Am AMALGAMATED LIFE Ambetter AmeriBen AMERICAN MEDICAL SECURITY AMERICAN PIONEER LIFE American Public Life Amerigroup AMERISYS Anchor Benefit Consulting APWU HEALTH PLAN Assurant Health AUSA LIFE INSURANCE COMP, INC Auto Owners Insurance AVESIS Avmed B'NAI-B'RITH BANK OF AMERICA TRUST FUND BANKERS LIFE & CASUALTY BC BS FLORIDA BEECH STREET-MEDICAL BENEFIT MANAGEMENT COMPANY BENESIGHT Best Choice BRISTOL/CONNECTICUT GENERAL CARECREDIT/GEMB CBCA ADMINISTRATORS, INC. CELTIC CENTRAL STATE HEALTH/LIFE COMP CHAMPUS-PALMETTO GBA Cherokee Insurance Company CIGNA HEALTHCARE-TN CITY OF MARGATE City of North Lauderdale Coast to Coast Vision Disc Plan Colonial Penn Life Ins Comp Complete Benefits Solutions CONNECTICUT GENERAL LIFE INS CONSECO SENIOR HEALTH CO CONSTUTION STATE SERVICES, LLC CONTINENTAL GENERAL INSURANCE CO. CORESOURCE CORIS USA Correct Vision Corvel Corporation Coventry Health Care CREATIVE COLLECTION SERVICE DAVIS VISION Davis Vision Discount Plan Devoted Health Claims DIRECT ASSIGNMENT BENEFIT PLANS, INC DIVISION OF BLIND SERVICES DMERC Dr Contact Lens Dr. Contact Lens Emblem Health EMPIRE BC/BS NY EMPLOYEES BENEFIT ASSOCIATION EMPLOYERS MUTUAL, INC. EYEMED VDT EYEMED VISION CARE EYEMED VISION DISCOUNT PLAN F H P FEDAERAL HOME LIFE INSURANCE CO Federated Mutual Insurance FIRST HEALTH FIRST NATIONAL LIFE INS CO FIRST UNION FIRST UNITED AMERICAN LIFE INS FISERV HEALTH FLEI FLORIDA RETAIL FEDERATION FORTIS INSURANCE COMPANY Freedom Life GALLAGHER BENEFITS ADMIN GEHA GENERAL AMERICAN INSURANCE Gerber Life Insurance Company Globe Life GOLDEN RULE INSURANCE CO. GREAT-WEST HEALTHCARE GREAT-WEST HEALTHCARE GROUP & PENSION ADMIN, INC. GROUP HEALTH INS Guaranteed Trust Life GUARDIAN INSURANCE Hartford HEALTH ADVANTAGE PLAN HEALTH AND WELFARE FUND HEALTH COMP INSURANCE Health Equity Health Partners HEALTH PLAN OF AMERICA Health Scope Health Sun Healthnet Patient Centered Community Care Heritage Vision Plan HRM CLAIM MANAGEMENT, INC. HSA ACCT HUMANA INS CO IBEW Impact Health Sharing INDECS INDEPENDENT HEALTH INSURANCE CENTER Integra KANAWHA INSURANCE COMPANY LAWYERS LION'S CLUB MagnaCare MAIL HANDLERS BENEFIT PLAN MCS Plaza MEBA MEDICAL PLAN MEDICA INSURANCE COMPANY MEDICAID CONSULTEC MEDICAL BENEFIT ADMIN MEDICAL MUTUAL Medicare Part B Claims Medico Insurance Company Memorial Managed Care Plan Meritain Health Insurance METROPOLITIAN CASULATY INS MILLENNIUM LASER EYE CENTER MMA MMM of Florida Monumental Life Insurance Co MOTOROLA CLAIM SERVICES MSK GROUP MSLA Mutual Health Services MUTUAL OF OMAHA MUTUAL PROTECTIVE INS CO MVP Insurance Nassau Life Insurance NAT ASSOC OF LETTER CARRIERS NATIONAL EMPLOYEES HEALTH PLAN NATIONAL STATES OXFORD PLAN NATIONAL VISION ADMINISTRATORS Nationwide NEIGHBORHOOD HEALTH PLAN NEW ERA LIFE INS CO NEW YORK LIFE NEW YORK STATE BENEFIT NORTH SHORE HEALTH SYSTEM NY CARPENTERS WELFARE FUND NY ST CLAIMS/UNITED HEALTHCARE ophthalmology consultants OPTACOMP OPTI CHOICE OPTICARE MANAGED VISION Oscar Health Plan Inc. OUT OF NETWORK OXFORD HEALTH INSURANCE, INC. PAN AMERICAN LIFE INS PERFORMAX PHYSICIAN'S MUTUAL INSURANCE PMA Companies POE & BROWN POMCO Pop Healthcare POSTMASTER BENEFIT PLAN Preferred Care Partners PREVINTER PRIMARY PLUS PRINCIPAL HEALTH CARE PRINCIPAL LIFE INSURANCE COMP PRIORITY HEALTH PRIVATE PRIVATE HEALTH CARE SYSTEMS PROGRESSIVE AMERICAN INSURANCE PROVIDENT LIFE AND ACCIDENT RAILROAD MEDICARE Rand Eye Institute RPS Samba Health Benefit Plan SANUS HEALTH CORPORATION Security Life SEDGWICK CLAIMS MANAGEMENT Seminole Tribe of Florida Health Plan SHASTA ADMINISTRATIVE SERVICES Sheet Metal Workers Wraparound Plus Sightbox Sightrust Eye Institute PA Simply Healthcare Sisco Solis Solstice Source Access, Inc. SOUTHCARE PPO Special Insurance Service SPECTERA Staar Study Standard Insurance Company STANDARD LIFE INSURANCE STAR ADMINISTRATIVE SERVICES STATE FARM INSURANCE COMPANIES STEAMFITTERS LOCAL 439 HEALTH & WELFARE STIRLING & STIRLING, INC. Stonebridge Life Insurance Company Sunshine State Health Plan SUPERIOR VISION PLAN The Empire Plan THE GUARDIAN LIFE INS COMPANY The Loomis Company THE MAIL HANDLERS BENEFIT PLAN THE ULLICO FAMILY OF COMPANIES THE ZENITH COMPANY TLC TOWER LIFE INS COMP/T.L. BLDG transamerica life ins co TRICARE EAST Triwest UFT WELFARE FUND UMR UNICARE UNICARE STATE INDEMNITY PLAN UNION FIDELITY LIFE INSURANCE UNISYS UNITED AMERICAN INS UNITED FOOD & COMMERCIAL WRKER UNITED HEALTHCARE UNITED TEACHER ASSOCIATES INS. CO. UNIVERA UNIVERSAL HEALTHCARE INC. UNUM USAA LIFE INS COMP ATTN CLAIMS USIA/JONES & MERCER EMP BEN VA -US Dept of Veteran Affairs VCI VISION BENEFITS OF AMERICA VISION QUEST-FLORIDA VSP VSP-MEDICAL VSP-VDT WARD NORTH AMERICA WAUSAU BENEFITS INSURANCE Wells Fargo Bank, NA Zurich
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary On Account

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:

Chief Complaint

Reason For Visit:


PATIENT OCULAR HISTORY

Please select if you have had any of the following:
Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders None
Please select your current Eye Meds:
None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink
Last Eye Doctor:
Last Eye Exam:
1 year 2 years 3 years over 3 years
 

Glasses and Contact lens History

Primary Vision Correction: 
None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA

Do you have back up glasses?
Yes No
Do you have sunglasses?
Yes No

Planning to get new glasses?
Yes No

Do you wear contact lenses
Yes No

FAMILY OCULAR HISTORY

Glaucoma:

No Parents Sibling Grandparent

Crossed / Lazy:

No Parents Siblings Grandparent

Retinal Detach:

No Parents Siblings Grandparent

Macular Degeneration:

No Parents Siblings Grandparent

Cataracts:

No Parents Siblings Grandparent

Medical History

PATIENT MEDICAL HISTORY

GENERAL: Fever, weight loss, weight gain, fatigue?

None Fever weight loss weight gain fatigue

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat

None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease

None Hyperlipidemia Vascular Disease HBP Heart Surgery COPD Atrial Fibrillation CAD Carotid Artery Disease MVP

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

None Asthma Bronchitis Emphysema COPD

GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence

None painful urination frequent urination impotence yellow jaundice

MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury

None joint pain stiffness swelling cramps arthritis

SKIN: growths, rashes, acne

None pimples, warts growths rash

NEUROLOGICAL: Headaches, migraines, seizures

None numbness, paralysis headache seizures migraines

PSYCHIATRIC: Depression, Anxiety, Insomnia

None anxiety depression insomnia

ENDOCRINE: Thyroid, Diabetes

None diabetes hypothyroid hyperthoyroid

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems

None bleeding cholestrolemia anemia

ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV

None sneezing swelling redness itching hives lupus

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None Diarrhea Constipation Ulcer Acid Reflux

Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:
No Yes Unsure
Primary Care Physician:

Last Visit:
1 week 1 month 3 months 6 months 1 year 2 years
List any Vitamins or Over the Counter Medications you take:

Please list your current Prescription Medications:

No Current Medications
Please list all drug allergies:

No Known Drug Allergies

FAMILY MEDICAL HISTORY
Do you have a history of any of the following in your family? (Please select from the drop downs below.)
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid
Smoking Status:
Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked
How Long:

Alcohol:
No Yes Occasionally Socially
Type:
None Beer Wine Hard Liquor
How Long:



NOTES:

Preferred Language:
English French German Spanish  
Ethnicity:
  Non Hispanic or Latino Hispanic or Latino  
Race:
  American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White
 

Symptoms Survey

I Have Symptoms Of Dryness Or Irritation

I Get Migraines Or Light Sensitivity (Especially After Long Hours)?

I Have symptoms Of Frequent Headaches Or Eyestrain?

Office Forms

View HIPAA Waiverance
*I have read and understood the HIPAA Waiverance. Full Name Date

View Insurance Disclaimer
*I have read and understood the Insurance Disclaimer. Full Name Date

Final Tab

Please click button below to submit your info.