Online Patient Form

Demographics

Patient Information

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:		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
Primary Doctor	No Doctor Assigned Dr. Aguilar, Stephanie Dr. Casillas, Eric Dr. Frogozo, Melanie	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Insurance Information

Insurance Name:	None ACCESS ADMINISTRATORS, INC AETNA AETNA MEDICARE AFFORDABLE BENEFIT ADMINISTRATORS, INC AMERICAN FAMILY INSURANCE GROUP AMERICAN PIONEER LIFE INSURANCE Ameritas Life Insurance Corp ASSOCIATION & SOCIETY INSURANCE CORP ASSURANT HEALTH AVESIS BANKER'S LIFE & CASUALTY BENEFIT PLANNERS/UMR-0704 BLOCK VISION BLUE CROSS/BLUE SHIELD Boon-Chapman Administrators (SAPD-SAFD) CEBA Celtic Healthy Texas-Opticare Celtic Individual Health-Opticare ChampVA CHRISTIAN FIDELITY LIFE INSURANCE COMPANY CIGNA CIGNA VISION - DO NOT USE - LINK TO VSP CNIC HEALTH SOLUTIONS COMMUNITY FIRST MEDICAID CONSECO HEALTH PLAN COOPERATIVE BENEFIT ADMINISTRATORS CORE SOURCE COVENTRY COVENTRY ADVANTAGE (Medicare) DARS Davis Vision - Affinity (discount) DAVIS VISION (not providors) DEFINITY HEALTH DISCOUNT EBS, EMPLOYEE BENEFIT SERVICES EPIC Group EPOCH GROUP EyeMed Discount EYEMED VISION FAMILY LIFE INSURANCE COMPANY FIRST HEALTH NETWORK FISERV HEALTH FMH GEHA GOLDEN RULE INSURANCE (UHC NETWORK) GOVERNMENT PERSONNEL MUTUAL LIFE INSURANCE COMPANY/UMR GREAT WEST GROUP & PENSION ADMINISTRATORS GROUP RESOURCES GUARDIAN INSURANCE COMPANY HEALTH & WELFARE BENEFIT SYSTEMS, INC HEALTH AMERICA HEALTH COMP (FIRST HEALTH NETWORK) HEALTHSMART HUMANA ACCESS HUMANA GOLD HMO - Not Providers HUMANA GOLD PLUS (HMO) - Not Provider HUMANA MEDICARE HUMANA MILITARY (TRICARE STANDARD) HUMANA or HUMANA CHOICE PPO HUMANA VISION (COMP BENEFITS VISION) LIFE INVESTORS INSURANCE CO OF AMERICA LifeRe Insurance Company LIFEWISE OF OREGON MAIL HANDLERS BENEFIT PLAN MARITAIN (part of Texas True Choice) MEDICAID/TMHP MEDICAL MUTUAL OF OHIO MEDICARE- CARE IMPROVEMENT PLUS MEDICARE - NOVITAS SOLUTIONS MEDIGAP MEDIPLUS MOAA MERITAIN HEALTH MET LIFE VISION( VSP) Molina Healthcare of TX-Opticare Molina Medicare-Medicaid Plan-Opticare MultiPlan MUTUAL ASSURANCE ADMINISTRATORS, INC MUTUAL OF OMAHA MVP SELECT CARE National Association of Letter Carriers (NALC) NATIONAL ELEVATOR INDUSTRY HEALTH BENEFIT PLAN NATIONWIDE SPECIALTY HEALTH CLAIMS NEW ERA LIFE INSURANCE COMPANY Opticare Vision Plans P 5 Innovative Health PACIFICARE HMO PACIFICARE PPO PHCS (NOT PROVIDERS) PHYSICIANS MUTUAL PLANNED ADMINISTRATOR INC PREFERRED BENEFIT ADMINISTRATORS PREFERRED HEALTH SYSTEM PREVENT BLINDNESS TEXAS PRINCIPAL PROVIDENCE RISK & INSURANCES SERVICES,INC RAILROAD MEDICARE RESOURCE ONE SAFEGUARD VISION PLAN (NOT PROVIDERS) SECURE HORIZONS (UHC) SELECT BENEFIT ADMINISTRATORS OF AMERICA SMITH ADMINISTRATORS ST. FARM MUTUAL AUTOMOBILE INSURANCE COMPANY STANDARD LIFE & ACCIDENT INSURANCE STARBRIDGE (CIGNA NETWORK) STRA STRATEGIC RESOURCES COMPANY STUDENT RESOURCES SUPERIOR -OPITCARE Superior EPO Chip-Opticare Superior HPC(Foster Care)-Opticare Superior Star+Plus MMP-Opticare Superior Texas+Ambetter-Opticare SUPERIOR VISION PLAN TEXAS TRUE CHOICE (NOT PROVIDERS) THE HARTFORD INSURANCE TIME INSURANCE COMPANY TML INTERGOVERNMENTAL EMPLOYEE BENEFIT TRICARE FOR LIFE TRICARE PRIME TRICARE STANDARD True Benefit Administrators TRUE CHOICE USA UGS - GLOBAL CARE, INC UHC/SPECTERA UMR UNICARE Union Security Insurance Company (PHCS) UNITED AMERICAN INSURANCE UNITED HEALTH CARE UNITED HEALTH CARE HEALTH SELECT United Medical Resources (UMR) UNITED MEDICAL RESOURCES, INC UNITED OF OMAHA LIFE INSURANCE COMPANY UNIVERSAL HEALTHCARE INC USAA LIFE INSURANCE COMPANY VETERAN'S ADMINISTRATION VIACARE/VISTACARE VISION SERVICE PLAN VSP Access Plan (discount) WELLCARE WELLS FARGO
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

Insurance Information

Insurance Name:	None ACCESS ADMINISTRATORS, INC AETNA AETNA MEDICARE AFFORDABLE BENEFIT ADMINISTRATORS, INC AMERICAN FAMILY INSURANCE GROUP AMERICAN PIONEER LIFE INSURANCE Ameritas Life Insurance Corp ASSOCIATION & SOCIETY INSURANCE CORP ASSURANT HEALTH AVESIS BANKER'S LIFE & CASUALTY BENEFIT PLANNERS/UMR-0704 BLOCK VISION BLUE CROSS/BLUE SHIELD Boon-Chapman Administrators (SAPD-SAFD) CEBA Celtic Healthy Texas-Opticare Celtic Individual Health-Opticare ChampVA CHRISTIAN FIDELITY LIFE INSURANCE COMPANY CIGNA CIGNA VISION - DO NOT USE - LINK TO VSP CNIC HEALTH SOLUTIONS COMMUNITY FIRST MEDICAID CONSECO HEALTH PLAN COOPERATIVE BENEFIT ADMINISTRATORS CORE SOURCE COVENTRY COVENTRY ADVANTAGE (Medicare) DARS Davis Vision - Affinity (discount) DAVIS VISION (not providors) DEFINITY HEALTH DISCOUNT EBS, EMPLOYEE BENEFIT SERVICES EPIC Group EPOCH GROUP EyeMed Discount EYEMED VISION FAMILY LIFE INSURANCE COMPANY FIRST HEALTH NETWORK FISERV HEALTH FMH GEHA GOLDEN RULE INSURANCE (UHC NETWORK) GOVERNMENT PERSONNEL MUTUAL LIFE INSURANCE COMPANY/UMR GREAT WEST GROUP & PENSION ADMINISTRATORS GROUP RESOURCES GUARDIAN INSURANCE COMPANY HEALTH & WELFARE BENEFIT SYSTEMS, INC HEALTH AMERICA HEALTH COMP (FIRST HEALTH NETWORK) HEALTHSMART HUMANA ACCESS HUMANA GOLD HMO - Not Providers HUMANA GOLD PLUS (HMO) - Not Provider HUMANA MEDICARE HUMANA MILITARY (TRICARE STANDARD) HUMANA or HUMANA CHOICE PPO HUMANA VISION (COMP BENEFITS VISION) LIFE INVESTORS INSURANCE CO OF AMERICA LifeRe Insurance Company LIFEWISE OF OREGON MAIL HANDLERS BENEFIT PLAN MARITAIN (part of Texas True Choice) MEDICAID/TMHP MEDICAL MUTUAL OF OHIO MEDICARE- CARE IMPROVEMENT PLUS MEDICARE - NOVITAS SOLUTIONS MEDIGAP MEDIPLUS MOAA MERITAIN HEALTH MET LIFE VISION( VSP) Molina Healthcare of TX-Opticare Molina Medicare-Medicaid Plan-Opticare MultiPlan MUTUAL ASSURANCE ADMINISTRATORS, INC MUTUAL OF OMAHA MVP SELECT CARE National Association of Letter Carriers (NALC) NATIONAL ELEVATOR INDUSTRY HEALTH BENEFIT PLAN NATIONWIDE SPECIALTY HEALTH CLAIMS NEW ERA LIFE INSURANCE COMPANY Opticare Vision Plans P 5 Innovative Health PACIFICARE HMO PACIFICARE PPO PHCS (NOT PROVIDERS) PHYSICIANS MUTUAL PLANNED ADMINISTRATOR INC PREFERRED BENEFIT ADMINISTRATORS PREFERRED HEALTH SYSTEM PREVENT BLINDNESS TEXAS PRINCIPAL PROVIDENCE RISK & INSURANCES SERVICES,INC RAILROAD MEDICARE RESOURCE ONE SAFEGUARD VISION PLAN (NOT PROVIDERS) SECURE HORIZONS (UHC) SELECT BENEFIT ADMINISTRATORS OF AMERICA SMITH ADMINISTRATORS ST. FARM MUTUAL AUTOMOBILE INSURANCE COMPANY STANDARD LIFE & ACCIDENT INSURANCE STARBRIDGE (CIGNA NETWORK) STRA STRATEGIC RESOURCES COMPANY STUDENT RESOURCES SUPERIOR -OPITCARE Superior EPO Chip-Opticare Superior HPC(Foster Care)-Opticare Superior Star+Plus MMP-Opticare Superior Texas+Ambetter-Opticare SUPERIOR VISION PLAN TEXAS TRUE CHOICE (NOT PROVIDERS) THE HARTFORD INSURANCE TIME INSURANCE COMPANY TML INTERGOVERNMENTAL EMPLOYEE BENEFIT TRICARE FOR LIFE TRICARE PRIME TRICARE STANDARD True Benefit Administrators TRUE CHOICE USA UGS - GLOBAL CARE, INC UHC/SPECTERA UMR UNICARE Union Security Insurance Company (PHCS) UNITED AMERICAN INSURANCE UNITED HEALTH CARE UNITED HEALTH CARE HEALTH SELECT United Medical Resources (UMR) UNITED MEDICAL RESOURCES, INC UNITED OF OMAHA LIFE INSURANCE COMPANY UNIVERSAL HEALTHCARE INC USAA LIFE INSURANCE COMPANY VETERAN'S ADMINISTRATION VIACARE/VISTACARE VISION SERVICE PLAN VSP Access Plan (discount) WELLCARE WELLS FARGO
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:

Tertiary

Insurance Information

Insurance Name:	None ACCESS ADMINISTRATORS, INC AETNA AETNA MEDICARE AFFORDABLE BENEFIT ADMINISTRATORS, INC AMERICAN FAMILY INSURANCE GROUP AMERICAN PIONEER LIFE INSURANCE Ameritas Life Insurance Corp ASSOCIATION & SOCIETY INSURANCE CORP ASSURANT HEALTH AVESIS BANKER'S LIFE & CASUALTY BENEFIT PLANNERS/UMR-0704 BLOCK VISION BLUE CROSS/BLUE SHIELD Boon-Chapman Administrators (SAPD-SAFD) CEBA Celtic Healthy Texas-Opticare Celtic Individual Health-Opticare ChampVA CHRISTIAN FIDELITY LIFE INSURANCE COMPANY CIGNA CIGNA VISION - DO NOT USE - LINK TO VSP CNIC HEALTH SOLUTIONS COMMUNITY FIRST MEDICAID CONSECO HEALTH PLAN COOPERATIVE BENEFIT ADMINISTRATORS CORE SOURCE COVENTRY COVENTRY ADVANTAGE (Medicare) DARS Davis Vision - Affinity (discount) DAVIS VISION (not providors) DEFINITY HEALTH DISCOUNT EBS, EMPLOYEE BENEFIT SERVICES EPIC Group EPOCH GROUP EyeMed Discount EYEMED VISION FAMILY LIFE INSURANCE COMPANY FIRST HEALTH NETWORK FISERV HEALTH FMH GEHA GOLDEN RULE INSURANCE (UHC NETWORK) GOVERNMENT PERSONNEL MUTUAL LIFE INSURANCE COMPANY/UMR GREAT WEST GROUP & PENSION ADMINISTRATORS GROUP RESOURCES GUARDIAN INSURANCE COMPANY HEALTH & WELFARE BENEFIT SYSTEMS, INC HEALTH AMERICA HEALTH COMP (FIRST HEALTH NETWORK) HEALTHSMART HUMANA ACCESS HUMANA GOLD HMO - Not Providers HUMANA GOLD PLUS (HMO) - Not Provider HUMANA MEDICARE HUMANA MILITARY (TRICARE STANDARD) HUMANA or HUMANA CHOICE PPO HUMANA VISION (COMP BENEFITS VISION) LIFE INVESTORS INSURANCE CO OF AMERICA LifeRe Insurance Company LIFEWISE OF OREGON MAIL HANDLERS BENEFIT PLAN MARITAIN (part of Texas True Choice) MEDICAID/TMHP MEDICAL MUTUAL OF OHIO MEDICARE- CARE IMPROVEMENT PLUS MEDICARE - NOVITAS SOLUTIONS MEDIGAP MEDIPLUS MOAA MERITAIN HEALTH MET LIFE VISION( VSP) Molina Healthcare of TX-Opticare Molina Medicare-Medicaid Plan-Opticare MultiPlan MUTUAL ASSURANCE ADMINISTRATORS, INC MUTUAL OF OMAHA MVP SELECT CARE National Association of Letter Carriers (NALC) NATIONAL ELEVATOR INDUSTRY HEALTH BENEFIT PLAN NATIONWIDE SPECIALTY HEALTH CLAIMS NEW ERA LIFE INSURANCE COMPANY Opticare Vision Plans P 5 Innovative Health PACIFICARE HMO PACIFICARE PPO PHCS (NOT PROVIDERS) PHYSICIANS MUTUAL PLANNED ADMINISTRATOR INC PREFERRED BENEFIT ADMINISTRATORS PREFERRED HEALTH SYSTEM PREVENT BLINDNESS TEXAS PRINCIPAL PROVIDENCE RISK & INSURANCES SERVICES,INC RAILROAD MEDICARE RESOURCE ONE SAFEGUARD VISION PLAN (NOT PROVIDERS) SECURE HORIZONS (UHC) SELECT BENEFIT ADMINISTRATORS OF AMERICA SMITH ADMINISTRATORS ST. FARM MUTUAL AUTOMOBILE INSURANCE COMPANY STANDARD LIFE & ACCIDENT INSURANCE STARBRIDGE (CIGNA NETWORK) STRA STRATEGIC RESOURCES COMPANY STUDENT RESOURCES SUPERIOR -OPITCARE Superior EPO Chip-Opticare Superior HPC(Foster Care)-Opticare Superior Star+Plus MMP-Opticare Superior Texas+Ambetter-Opticare SUPERIOR VISION PLAN TEXAS TRUE CHOICE (NOT PROVIDERS) THE HARTFORD INSURANCE TIME INSURANCE COMPANY TML INTERGOVERNMENTAL EMPLOYEE BENEFIT TRICARE FOR LIFE TRICARE PRIME TRICARE STANDARD True Benefit Administrators TRUE CHOICE USA UGS - GLOBAL CARE, INC UHC/SPECTERA UMR UNICARE Union Security Insurance Company (PHCS) UNITED AMERICAN INSURANCE UNITED HEALTH CARE UNITED HEALTH CARE HEALTH SELECT United Medical Resources (UMR) UNITED MEDICAL RESOURCES, INC UNITED OF OMAHA LIFE INSURANCE COMPANY UNIVERSAL HEALTHCARE INC USAA LIFE INSURANCE COMPANY VETERAN'S ADMINISTRATION VIACARE/VISTACARE VISION SERVICE PLAN VSP Access Plan (discount) WELLCARE WELLS FARGO
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!

Patient Information

My visit today is for:	Glasses	Contact Lenses
	Office Visit	Laser Vision Correction

How did you find out about our office?

Date of Last Eye Exam:

By Doctor:

Social History

Hours Spent on Computer:

Do you drive?

Yes

No

Do you have visual difficulty while driving?

Yes

No

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

Do you use illegal drugs?

Yes

No

Type/Frequency:

Any history of STDs?

Yes

No

Medical History

Are you Pregnant/Nursing?

Yes

No

List any Health Problems:

List any Medications:

Over the Counter Medications:

None Vitamins Antihistamine Ibuprofen Tylenol Fish Oil Omega 3s ASA 82 mg ASA 325 mg Other

Are you allergic to any medication?

Yes

No

Medication Allergy:

None known Sulfa PCN ASA Iodine Erythromycin Codeine Other

Eye Injuries (foreign objects, black eye, etc.)	Yes	No
Eye Disease (cataract, glaucoma, mac degen, etc.)	Yes	No
Eye Surgery (cataract, laser vision correction, etc.)	Yes	No

If Yes, Please explain:

Do you wear contacts?

Yes

No

What Type?:

Review of Systems

General:	Good Pregnant Fair Poor Other
Eyes:	None Eye pain/soreness Fatigue/tired eyes Dry/gritty feeling Redness Burning Itching Excess Watering Mucous discharge Squinting Glare/light sensitivity Halos around lights Double vision Loss of vision Blurred vision Flashes Floaters Other
Skin:	None Rosacea Metal allergies Other

Endocrine:	None Thyroid/other glands Diabetes Post Menopause Other
Psychiatric:	None Anxiety Depression Insomnia Other
Respiratory:	None Asthma Chronic bronchitis Emphysema Other
Neurological:	None Headaches Seizures Alzheimer's Parkinson's Other

Genitourinary:	None Urinary problems Kidney problems Genital problems Other
Constitutional:	None Fever Weight loss or gain Other
Gastrointestinal:	None Acid reflux Intestinal problems Liver/spleen problems Other
Immune System:	None Immunocompromised Other

Muscles, Bones, Joints:	None Rheumatoid arthritis Muscle/joint pain Other
Lymphatic/Hematologic:	None Anemia Bleeding Other
Vascular/Cardiovascular:
Ears, Nose, Throat, Mouth:	None Allergies/hay fever Sinus infections Hearing loss Dry mouth Other

Family Eye History:	None known Cataracts Amblyopia ARMD Glaucoma Retinal Detachment Adopted Other
Family Medical History:	None Known Artheritis Diabetes Hypercholesterolmia Heart Dx HBP Cancer Thyroid Adopted Other

Consent and Submit Data

Dilation of the Pupils

I do consent to having my eyes dilated

I do understand the importance of dilation, yet, I do not wish to have it performed at this time. I release Alamo Eye Care and Dr. Melanie Frogozo from any liabilities related to the failure to diagnose or treat any eye condition due to the lack of diagnostic information that could have been obtained by the test.

Patient's Signature:

Date: