Online Patient Form
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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
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
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
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
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer / School Name
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Yes
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
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
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Insurance Information
Insurance Name:
None
New Insurance
New Insurance
20/20
AARP
ADP - Payroll
ADP - Payroll
Advantica
AETNA
Avesis
Blue Cross Blue Shield
Care Credit
CIGNA
Davis - 365 discount plan
Davis - Discount plan
Davis Vision
DMERC Region C Medicare
Eyemed
GHI
Health First Health Plans
Health Net - VA Patient Centered Community Care Prog
Humana PPO
Medi-Share
Medical Mutual of Ohio
Medicare A DMERC
Medicare B First Coast Service Options
Medicare B DMERC
Medicare D DMERC
Mega Life And Health Insurance
New Insurance
New Insurance
Premiere Eyecare (Wellcare)
Spectera
Superior
United Healthcare
United Healthcare (AARP)
VCP
VSP
Wellcare
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 choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Do you wear glasses?:
None
Glasses-Full Time
Glasses-Readers Only
Other
Age of Glasses:
Do you wear contact lenses?:
None
Disposable
Conventional
Colored
RGP
PMMA
Other
Are they soft disposable / RGP / Other?:
How old are they?:
What brand are they?:
Do you want to be fit with contact lenses today?:
Are you having problems with your vision, your glasses or your contact lenses? Please explain:
Have you had your eyes dilated before?:
Medical History
Yes
No
1.
Pregnant/Nursing
2.
Injuries
3.
Allergies
4.
Surgeries
5.
Cataracts/Surgery
6.
Lazy Eye
7.
Droopy Lids
8.
Crossed Eyes
9.
Diabetes
Type I
Type II
Yes
No
10.
Eye Infections
11.
Prominent Eyes
12.
Glaucoma
13.
Eye Injuries
14.
Headaches
15.
Migraines
16.
LASIK Surgery
17.
Double Vision
Yes
No
18.
Retinal Detachment
19.
Retinal Disease
20.
Stroke
21.
Heart Disease
22.
High Blood Pressure
23.
See Spots/Flashes
24.
Thyroid Problem
25.
Heart Attack
26.
Medications
If you checked Yes to any of the above, explain and list any medications:
Family History
Yes
No
1.
Blindness
2.
Cataract
3.
Crossed Eyes
4.
Glaucoma
5.
Diabetes
6.
Lupus
Yes
No
7.
Heart Disease
8.
High Blood Pressure
9.
Kidney Disease
10.
Thyroid Disease
11.
Arthritis
12.
Cancer
Yes
No
13.
Retinal Disease
14.
Retinal Detachment
15.
Macular Degeneration
16.
Other:
Please explain:
Social History
Do you drive?:
Yes
No
Do you have visual difficulty while driving?:
Do you use tobacco products?:
Yes
No
Do you drink alcohol?:
Yes
No
Do you use illegal drugs?:
Yes
No
Have you ever been exposed to or infected with Hepatitis or HIV?:
Review of Systems
- Do you currently, or have you ever had any problems in the following areas?:
Yes
No
Constitutional
Fever, Weight Loss/Gain
Skin
Skin Condition
Neurological
Headaches
Migraines
Seizures
Eyes
Loss of Vision
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy/Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing/Watering
Glare/Light Sensitivity
Eye Pain/Soreness
Chronic Eye/Lid Infection
Sties/Chalazion
Flashes/Floaters
Tired Eyes
Endocrine
Thyroid/Gland Condition
Diabetes
Yes
No
Ears/Nose/Mouth/Throat
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth
Respiratory
Asthma
Chronic Bronchitis
Emphysema
Cardiovascular
Heart Pain
High Blood Pressure
Vascular Disease
Gastrointestinal
Diarrhea
Constipation
Genitourinary
Genitourinary
Genitourinary Condition
Musculoskeletal
Rheumatoid Arthritis
Muscle Pain
Joint Pain
Blood/Lymph
Anemia
Bleeding Problems
Allergy/Immune
Allergy/Immune Condition
Psychiatric
Psychiatric Condition
If you answered yes to any of the above or have a condition not listed, please explain and list medications:
I request that payment of authorized Medicare benefits or other insurance be made either to me or on my behalf to Dr. Smith or any services furnished to me by that doctor. I authorize and holder of medical information about me to release to the health care financing administration and its agent any information needed to determine these benefits or the benefits payable for related services.
Lifetime Patient Signature:
Date:
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