Online Patient Form

Primary Medical Insurance

Insurance Name:	None New Insurance New Insurance New Insurance 3M Safety AARP Healthcare Options ABERCROMBIE, SIMMONS & GILLETTE, INC. AEARO Aetna Airgas Optics (Safety) All All Savers Allied Benefit Systems, Inc. Always Vision / Always Care Ambetter from Superior HealthPlan Ameriben AMFirst Ins. Co. AO SAFETY APWU Assurant Health Avesis AVMA Grp Health & Life Ins. Trust Bankers Life & Casualty Co Benefit Mgmt. Services Bennefit Planners Block Vision Blue Cross/Blue Shield Boilermakers Nat'lL Health & Welfare Fund Boon - Chapman Business Admin. Assc. Care Improvement Plus Caremark CASH PAY Central States Indemnity Central United Champva Christian Fidelity Christian Healthcare Ministries Christus Health Cigna Cigna Interantional Cigna Star Bridge Cigna Visioncare Cleat Coast to Coast Vision Colonial Supp. Ins. Combined Insurance Community Health Choice - CHIPS CompBenefits Connecticut General Life Ins. Conseco Consolidated Asscn. For Railroad Employees Continental General Continental Life Insurance Cooperative Bennefit Administrator CoreSource Coventry Health Care Dallas General Davis Vision Davis Vision Discount DMERC Dragon Products Employee Benefit Services of LA Entrust Envolve Essilor Safety EyeMed Vision Care FedEx Freight East Fidelity Security Life Ins. First Health Network Fiserv Health Services Fortis Fox Everett Ins. GEHA Gilsbar, Inc. Golden Rule Ins. Co. GREAT WEST-CIGNA GREENTREE HealthSmart PPO Plus HEALTHSMART PREFERRRED CARE HealthSpring HOMELAND HEALTHCARE HUMANA IBEW-NECA SOUTHWESTERN HEALTH & BENEFIT FUND LINCOLN HERITAGE Loyal American Life Ins. Co. Maxcare MEAD WESTVACO Medi-Share Medical Mutual Medicare-Texas Medico Ins. Co. MEGA LIFE & HEALTH INS. CO, MEMORIAL HERMAN HNP Meritain Health MES VISION Mississippi Administrative Service, Inc. Molina MUTUAL OF OMAHA MVP Health Care NALC HEALTH BENEFIT PLAN NAMIC Vision Nat"l Automatic Sprinkler Industry Welfare Fund NATIONAL VISION ADMIN. NEW ERA LIFE INS. CO. Nexcaliber Nippon Life NRECA (COOPERATIVE BENEFIT ADMINISTRATORS) Old Surety Life Omaha Insurance Company OPTICARE VISION Optum Health - Optum Health ORR SAFETY Pan American Life PERSONNEL STAFFING PHCS PHYSCIAN'S MUTUAL PHYSICIANS LIFE INS. CO. PREFERRED CHOICE FOR SENIORS Primary Physician's Care PRINCIPAL LIFE INS. CO. PYRAMID RAILROAD MEDICARE RESERVE NATIONAL INS. CO. Rural Carriers Benefit Plan Sabine-Neches Private Clinic SCOTT & WHITE HEALTH PLAN SecureHorizons SELECT CARE OF TEXAS SHENANDOAH LIFE INS. CO. SIERRA HEALTH & LIFE INS. CO., INC SIGNAL INTERNATIONAL SILSBEE ISD SOUTHERN OPERATORS HEALTH FUND Southwest Life Insurance Spectera Standard Life Star Health (Superior Health) Starmark STATE FARM STERLING OPTION 1 Superior Health Plan SUPERIOR VISION Texan Plus Texas Comptroller of Public Accts. Texas Diabetes Program Texas Home Health Texas Medicaid Texas Mediciad-Superior Health Plan Foster Texas Municipal League Texas Mutual Texas True Choice Christus Health The Standard TML Intergovernmental Employee Benefits Pool Today's Options Advantage Plus Tower Life Ins. Co. Transamerica Life Ins. Tri - Care Tri West Tx. Children's Health Plan - CHIPS Tx. Medicaid - Amerigroup Tx. Medicaid - Children's Health Plan Tx. Medicaid - Community Health Choice Tx. Medicaid - Molina Tx. Medicaid - UHC TX. Mediciaid UHC- Community Plan U.A. PLUMBERS UNION # 68 UHC-Community Plan UMR UNICARE United American United Healthcare United Healthcare - CHIPS Unknown US Family Health Plan USAA Life Ins. Co. VBA VCP VISION ONE VS Savings Plan VSP - Vision Service Plan WAUSAU BENEFITS WOODMEN OF THE WORLD ASSURED LIFE ASSCN. WORKMAN'S COMP
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 Medical Insurance

Insurance Name:	None New Insurance New Insurance New Insurance 3M Safety AARP Healthcare Options ABERCROMBIE, SIMMONS & GILLETTE, INC. AEARO Aetna Airgas Optics (Safety) All All Savers Allied Benefit Systems, Inc. Always Vision / Always Care Ambetter from Superior HealthPlan Ameriben AMFirst Ins. Co. AO SAFETY APWU Assurant Health Avesis AVMA Grp Health & Life Ins. Trust Bankers Life & Casualty Co Benefit Mgmt. Services Bennefit Planners Block Vision Blue Cross/Blue Shield Boilermakers Nat'lL Health & Welfare Fund Boon - Chapman Business Admin. Assc. Care Improvement Plus Caremark CASH PAY Central States Indemnity Central United Champva Christian Fidelity Christian Healthcare Ministries Christus Health Cigna Cigna Interantional Cigna Star Bridge Cigna Visioncare Cleat Coast to Coast Vision Colonial Supp. Ins. Combined Insurance Community Health Choice - CHIPS CompBenefits Connecticut General Life Ins. Conseco Consolidated Asscn. For Railroad Employees Continental General Continental Life Insurance Cooperative Bennefit Administrator CoreSource Coventry Health Care Dallas General Davis Vision Davis Vision Discount DMERC Dragon Products Employee Benefit Services of LA Entrust Envolve Essilor Safety EyeMed Vision Care FedEx Freight East Fidelity Security Life Ins. First Health Network Fiserv Health Services Fortis Fox Everett Ins. GEHA Gilsbar, Inc. Golden Rule Ins. Co. GREAT WEST-CIGNA GREENTREE HealthSmart PPO Plus HEALTHSMART PREFERRRED CARE HealthSpring HOMELAND HEALTHCARE HUMANA IBEW-NECA SOUTHWESTERN HEALTH & BENEFIT FUND LINCOLN HERITAGE Loyal American Life Ins. Co. Maxcare MEAD WESTVACO Medi-Share Medical Mutual Medicare-Texas Medico Ins. Co. MEGA LIFE & HEALTH INS. CO, MEMORIAL HERMAN HNP Meritain Health MES VISION Mississippi Administrative Service, Inc. Molina MUTUAL OF OMAHA MVP Health Care NALC HEALTH BENEFIT PLAN NAMIC Vision Nat"l Automatic Sprinkler Industry Welfare Fund NATIONAL VISION ADMIN. NEW ERA LIFE INS. CO. Nexcaliber Nippon Life NRECA (COOPERATIVE BENEFIT ADMINISTRATORS) Old Surety Life Omaha Insurance Company OPTICARE VISION Optum Health - Optum Health ORR SAFETY Pan American Life PERSONNEL STAFFING PHCS PHYSCIAN'S MUTUAL PHYSICIANS LIFE INS. CO. PREFERRED CHOICE FOR SENIORS Primary Physician's Care PRINCIPAL LIFE INS. CO. PYRAMID RAILROAD MEDICARE RESERVE NATIONAL INS. CO. Rural Carriers Benefit Plan Sabine-Neches Private Clinic SCOTT & WHITE HEALTH PLAN SecureHorizons SELECT CARE OF TEXAS SHENANDOAH LIFE INS. CO. SIERRA HEALTH & LIFE INS. CO., INC SIGNAL INTERNATIONAL SILSBEE ISD SOUTHERN OPERATORS HEALTH FUND Southwest Life Insurance Spectera Standard Life Star Health (Superior Health) Starmark STATE FARM STERLING OPTION 1 Superior Health Plan SUPERIOR VISION Texan Plus Texas Comptroller of Public Accts. Texas Diabetes Program Texas Home Health Texas Medicaid Texas Mediciad-Superior Health Plan Foster Texas Municipal League Texas Mutual Texas True Choice Christus Health The Standard TML Intergovernmental Employee Benefits Pool Today's Options Advantage Plus Tower Life Ins. Co. Transamerica Life Ins. Tri - Care Tri West Tx. Children's Health Plan - CHIPS Tx. Medicaid - Amerigroup Tx. Medicaid - Children's Health Plan Tx. Medicaid - Community Health Choice Tx. Medicaid - Molina Tx. Medicaid - UHC TX. Mediciaid UHC- Community Plan U.A. PLUMBERS UNION # 68 UHC-Community Plan UMR UNICARE United American United Healthcare United Healthcare - CHIPS Unknown US Family Health Plan USAA Life Ins. Co. VBA VCP VISION ONE VS Savings Plan VSP - Vision Service Plan WAUSAU BENEFITS WOODMEN OF THE WORLD ASSURED LIFE ASSCN. WORKMAN'S COMP
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

Do you have any of these eye symptoms?:

None Itching Burning, Stinging Red Floaters Flashes Of Light Eye Injuries Eye Surgery Amblyopia Strabismus Cataracts Glaucoma Retinal Disorders Other

Do you take any eye medications?:

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

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA OTC readers Other

Do you have backup glasses?:

No Yes Other

Want new glasses?:

Yes No Other

Type of CLs 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

Family Eye History

Macular Degen:	No Parents Siblings Grandparent Other	Glaucoma:	No Parents Sibling Grandparent Other
Retinal Detach:	No Parents Siblings Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other
Crossed/Lazy Eye:	No Parents Siblings Grandparent Other

Review of Systems

General:	none fatigue fever loss of appetite weight gain weight loss Other	Ear/Nose/Throat:	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other
Respiratory:	none asthma cronchitis cyanosis emphysema productive cough shortness of breath wheezing Other	Cardiovascular:	none chest pain heart disease high cholesterol hypertension racing heartbeat shortness of breath swollen feet/ankles vascular disease Other
Skin:	none acne eczema itching psoriasis rosacea Other	Genitourinary:	none impotence jaundice overactive bladder painful urination painful urination underactive bladder urgency in urination urinary incontinence Other
Psychiatric:	none anxiety depression insomnia obsessive/compulsive paranoia suicidal violence Other	Musculoskeletal:	none arthritis decreased range of motion muscle cramps pain/tenderness stiffness swelling weakness Other
Neurological:	none balance problems changes in senses dementia memory problems muscle weakness numbness, paralysis personality changes speech problems tremors vertigo Other	Blood/Lymph:	none anemia bleeding gums cuts slow to clot easy bruising hx of significant blood loss nosebleeds pale skin pounding in ears rapid heartbeat shortness of breath Other
Endocrine:	None diabetes hypothyroid hyperthyroid Other	Allergic/Immune:	None sneezing swelling redness itching hives lupus Other
		Gastrointestinal:	None Diarrhea Constipation Ulcer Acid Reflux Other

Pregnant Or Nursing:

No Yes Unsure Other

Recent Tetanus Shot:

Yes No Other

Primary Care Physician*:

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years greater than 3 years Other

Reason:

Check up Annual Specific Other

Pharmacy Preference*:

Height*:	ft.	in.
Weight*:

Medications: No Meds	Allergies: No Known Drug Allergies

Vitamins:

None A E C Zinc Xanten Lutein Other

Over The Counter Meds:

None Aspirin Acetaminophen Ibuprofen Other

Have you had any injuries, surgeries, or hospitalizations?:

Family Medical History

Please describe any medical conditions that occur in your family, along with the relationship of the family member.

None Adopted Diabetes HBP Cancer Cardiovascular Disease Arthritis Kidney Disease Lupus Thyroid Other

Social History

Hobbies:

None Art Baseball Astronomy Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Smoking Status:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	Type:	None Cigarettes Chewing Tobacco Other	How Long:
Alcohol Use:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:		STD's?:	None Gonorrhea Syphilis Hepatitis HIV TB Other

Race:

White Black or African American Asian Patient Declined to Specify American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Race Other

Ethnicity:

Not Hispanic or Latino Hispanic or Latino Other Patient Declined to Specify Other

Preferred Language:

English French German Spanish Other

Submit Data

*Click here to view our HIPAA Privacy Policy*

Acknowledgment of Notice of Privacy Practices

The law requires that Doctor's Eye Clinic make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge one of the following:

I have read or had explained to me Doctor's Eye Clinic's Notice of Privacy Practice and agree to continue my care with Doctor's Eye Clinic under said terms.

OR

I was given the opportunity to read Doctor's Eye Clinic's Notice of Privacy Practice and did not wish to read it, but wish to continue my care with Doctor's Eye Clinic under the terms of Doctor's Eye Clinic's privacy policies.

OR

I have read or had explained to me Doctor's Eye Clinic's Notice of Privacy Practice and DO NOT wish to continue my care with Doctor's Eye Clinic under said terms.

I HAVE READ AND UNDERSTAND THIS FORM AND I AM SIGNING IT VOLUNTARILY:

Name of Patient:

Date:

Signature of Patient or Patient's Representative:

Relationship to Patient:

Name, Relation, Address, and Phone Number of those you authorize our office to release your private health information:

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