Online Patient Form


This form is loaded directly into your medical record. Please fill out all fields. Thank you!

Patient Information
Title First Last MI Suffix Preferred name
Address:
City: State ZipCode:
Home Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student
Part-Time Student
Marital Status Employer / School Name
Parent/Guardian
Billing Information Is The Billing Address the Same?
Title First Last MI Suffix
Address

City State ZipCode
Home Phone:
Work Phone:
Primary Vision Insurance
Insurance Name:
Insurance ID:
Insurance Policy Group:
If you are not the primary for this insurance, check the box and fill in details
Not Primary
Primary Medical Insurance
Insurance Name:
Insurance ID:
Insurance Policy Group:
If you are not the primary for this insurance, check the box and fill in details
Not Primary
Other Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
If you are not the primary for this insurance, check the box and fill in details
Not Primary
Eye History
Primary Reason for Visit
Additional Reason for Visit:

Last Eye Exam:

Current Vision Correction

Predominantly Wears:
Interested in CLs    Currently wears CLs    Currently wears Glasses

Personal Ocular History

Eye Diseases:


Eye Injuries:


Eye Surgeries:


Eye Medications:

Family Ocular History

Glaucoma: Blindness: Macular Degen:
Retinal Detach: Crossed / Lazy:
Medical History

Patient Medical History

Primary Care Physician: Last Visit:
Current Medications:
Injuries, Surgeries, Hospitalization
Pregnant Or Nursing:
Allergies to Medications:

Social History

Smoking Status:
Alcohol:
Illegal Drugs:

Visual Lifestyle

What hobbies do you do regularly?
(ex: sewing, reading, golf, etc)
Check the box if these apply to you:
Over 6 hours of computer / day
Regularly experience eyestrain, fatigue, or headaches while on the computer
Wears sunglasses outdoors
Review Of Systems

Do You Currently Have Any Of These Problems?

GENERAL:


EAR, NOSE, THROAT:


CARDIOVASCULAR:


RESPIRATORY:


GENITAL, KIDNEY, BLADDER:


MUSCLES, BONES, JOINTS:


SKIN:


NEUROLOGICAL:


PSYCHIATRIC:


ENDOCRINE:


BLOOD/LYMPH:


ALLERGIC / IMMUNOLOGIC:


GASTROINTESTINAL:

Family Medical History

Have your parents, grandparents or siblings had any of the following:

Signatures and Policies

Authorized Representative

Desert EyeCare Center may discuss my medical information and insurance information with:
Name:
Relationship:

Insurance Authorization, Financial Policy, and Consent To Treat

I request that payment of authorized insurance/Medicare benefits be made on my behalf to Desert EyeCare Center(DECC).This is to include medical services rendered by myself and/or dependents. I assume responsibility for any deductible, co-payment, or other balance not covered by my insurance carrier. Authorization obtained at the time of service does not guarantee payment. As a service to the patient, DECC will submit claims to your insurance carrier. However DECC cannot guarantee that these claims will be honored. All denied claims will be billed to the patient. I recognize that it is my responsibility to know and understand my insurance coverage, or lack thereof. I understand that professional fees are due upon completion of the exam, and that these services are non-refundable. I UNDERSTAND THAT ALL GLASSES AND CONTACT LENS ORDERS ARE NON-REFUNDABLE. I authorize the doctor to release all information necessary to secure payment of benefits.

I consent to Desert EyeCare Center to provide eye care services to myself and/or family.
Signature: (Please type your first and last name)
Date: (mm/dd/YYYY)

Vision Insurance vs. Medical Insurance

Desert EyeCare Center is required by law to follow proper coding and billing for eye/vision examinations. Your vision insurance will not pay for a medical eye condition and your medical insurance will not pay for your routine eye examination.
Vision Plan: Medical Plan: We are not allowed to bill both medical and vision insurances on the same day. If you have a medical eye problem, and still need glasses, we can handle it one of two ways. We can check your prescription the same day as your medical eye exam and bill you for the refraction (eyeglass prescription check), or you can come back on another day and we can bill your vision insurance for your refraction.

I understand that Vision and Medical insurances have different purposes and can't be used on the same day.

HIPAA Notice and Acknowledgment

Desert EyeCare Center's privacy policy is available for download here. By signing I accept this policy.
Signature: (Please type your first and last name)

Contact Lens Policy

If you are interested in Contact Lenses at your appointment, please review our contact lens policy here. By signing I accept this policy.
I have reviewed the Contact Lens Policy.
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