Online Patient Form

Demographics

Title:	Mr. Mrs. Ms. Dr. Rev. Fr. Miss
First Name:*
Last Name:*
Middle Initial:
Suffix:
Nickname:
Address:*
Apt/Suite #:
City:*
State:*	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
ZipCode:*
Home Phone:*
Work Phone:
Other Phone:
Email
Cell Phone:*
Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN (last 4 digits)
Occupation
DOB (mmddyyyy)*
Sex	Male Female
Employer/School Name:
Misc/Guardian

How did you hear about our office?	Friend/Family Physician Insurance Internet Walk by Other
Name of Referrer:

Billing Information

Is The Billing Address the Same? Yes

Title:	Mr. Mrs. Ms. Dr. Rev. Fr. Miss
First Name:
Last Name:
Middle Initial:
Suffix:
Address:
Apt/Suite #:
City:
State:	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
ZipCode:
Home Phone:
Work Phone:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Reason for Visit:

Secondary Reasons:

Medications: No Meds

Over The Counter Meds:

Vitamins:

Drug Allergies: None

Please describe any injuries or surgeries you have had:

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

Pregnant Or Nursing:

No Yes Unsure Other

Recent Tetanus Shot:

Yes No Other

Recent Flu Immunization:

Do you have any of these medical conditions? If yes, please describe:

Diabetes:		Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions? If yes, please describe:

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Eye History

Do you currently have any of these 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 of these 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

Have you had any eye surgeries? Please describe:

Last Eye Exam:

1 year 2 years 3 years Other

By Doctor:

Primary Vision Correction:

None Prescription Glasses Prescription Reading Glasses Soft Contacts Non-Prescription Reading Glasses Other

Do you:    Have back up glasses?

No Yes Other

Want new glasses?

Yes No Other

Want backup sunglasses?:

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

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
Lazy/Crossed 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 chronic cough congestion daytime drowsiness dry throat / mouth gasp while sleeping headache hearing problems heavy snoring morning headaches runny nose sinus problems sleep apnea tinnitus toothache Other
Skin:	none acne eczema itching psoriasis rosacea Other	Cardiovascular:	none chest pain heart disease high cholesterol hypertension racing heartbeat shortness of breath swollen feet/ankles vascular disease Other
Respiratory:	none asthma cronchitis cyanosis emphysema productive cough shortness of breath wheezing Other	Musculoskeletal:	none arthritis decreased range of motion muscle cramps pain/tenderness stiffness swelling weakness Other
Psychiatric:	none anxiety depression insomnia obsessive/compulsive paranoia suicidal violence Other	Gastrointestinal:	none abdominal pain acid reflux bloody stools constipation Crohn's disease dark urine diarrhea gastric reflux (GERD) IBS jaundice nausea ulcer vomiting Other
Endocrine:	none diabetes hypothyroid hyperthyroid 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
Neurological:	none balance problems changes in senses dementia memory problems muscle weakness numbness, paralysis personality changes speech problems tremors vertigo Other	Genitourinary:	none impotence jaundice overactive bladder painful urination painful urination underactive bladder urgency in urination urinary incontinence Other
Immune:	none asthma hives itching mild allergy symptoms redness severe allergy symptoms sneezing swelling Other

Social History

How many hours per day do you spend on the computer or hand held electronics?

How often do you take breaks?:

Have you noticed any of the following related to computer use? If yes, please check:

Blurred Vision	Headaches
Double Vision	Eye Strain
Dryness	Fatigue
Watery Eyes

What hobbies, sports, or other activities are you involved in?:

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

Do you have a need for specialty glasses for these activities?:
Yes No

Submit Data

Please read and agree to the terms below.


NOTICE OF PRIVACY PRACTICES

THIS NOTICE OF PRIVACY PRACTICES ("NOTICE") DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR
HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READ IT
CAREFULLY. Your "health information," for purposes of this Notice, is generally any information that identifies you and
is created, received, maintained or transmitted by us in the course of providing health care items or services to you
(referred to as "health information" in this Notice).

We are required by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and other applicable laws
to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy
practices with respect to such information, and to abide by the terms of this Notice. We are also required by law to notify
affected individuals following a breach of their unsecured health information.

USES AND DISCLOSURES OF INFORMATION WITHOUT YOUR AUTHORIZATION

The most common reasons why we use or disclose your health information are for treatment, payment or health care
operations. Examples of how we use or disclose your health information for treatment purposes are: setting up an
appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing
them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or
services; or getting copies of your health information from another professional that you may have seen before us.
Examples of how we use or disclose your health information for payment purposes are: asking you about your health or
vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts
(either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and
managerial functions that we must carry out in order to run our office. Examples of how we use or disclose your health
information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions;
participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

OTHER DISCLOSURES AND USES WE MAY MAKE WITHOUT YOUR AUTHORIZATION OR CONSENT

In some limited situations, the law allows or requires us to use or disclose your health information without your consent
or authorization. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or
disclosures are:

* When a state or federal law mandates that certain health information be reported for a specific purpose;
* For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from
   the federal Food and Drug Administration regarding drugs or medical devices;
* Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
* Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or
   Medicaid; or for investigation of possible violations of health care laws;
* Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or
   administrative agencies;
* Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a
   victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
* Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to
   aid in burial; or to organizations that handle organ or tissue donations;
* Uses or disclosures for health related research;
* Uses and disclosures to prevent a serious threat to health or safety;
* Uses or disclosures for specialized government functions, such as for the protection of the president or high ranking
   government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health
   of members of the foreign service;
* Disclosures of de-identified information;
* Disclosures relating to worker's compensation programs;
* Disclosures of a "limited data set" for research, public health, or health care operations;
* Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
* Disclosures to "business associates" and their subcontractors who perform health care operations for us and who
   commit to respect the privacy of your health information in accordance with HIPAA;

Unless you object, we will also share relevant information about your care with any of your personal representatives who
are helping you with your eye care. Upon your death, we may disclose to your family members or to other persons who
were involved in your care or payment for heath care prior to your death (such as your personal representative) health
information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed
to us prior to your death.

SPECIFIC USES AND DISCLOSURES OF INFORMATION REQUIRING YOUR AUTHORIZATION

The following are some specific uses and disclosures we may not make of your health information without your
authorization:

Marketing activities: We must obtain your authorization prior to using or disclosing any of your health information for
marketing purposes unless such marketing communications take the form of face-to-face communications we may make
with individuals or promotional gifts of nominal value that we may provide. If such marketing involves financial payment
to us from a third party your authorization must also include consent to such payment.

Sale of health information: We do not currently sell or plan to sell your health information and we must seek your
authorization prior to doing so.

Psychotherapy notes: Although we do not create or maintain psychotherapy notes on our patients, we are required to
notify you that we generally must obtain your authorization prior to using or disclosing any such notes.

YOUR RIGHTS TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES

* Other uses and disclosures of your health information that are not described in this Notice will be made only with
   your written authorization.
* You may give us written authorization permitting us to use your health information or to disclose it to anyone for any
   purpose.
* We will obtain your written authorization for uses and disclosures of your health information that are not identified in
   this Notice or are not otherwise permitted by applicable law.
* We must agree to your request to restrict disclosure of your health information to a health plan if the disclosure is for the
   purpose of carrying out payment or health care operations and is not otherwise required by law and such information
   pertains solely to a health care item or service for which you have paid in full (or for which another person other than
   the health plan has paid in full on your behalf).

Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you
in writing at any time. After you revoke your authorization, we will no longer use or disclose your health information for
the reasons described in the authorization. However, we are generally unable to retract any disclosures that we may have
already made with your authorization. We may also be required to disclose health information as necessary for purposes
of payment for services received by you prior to the date you revoked your authorization.

YOUR INDIVIDUAL RIGHTS

You have many rights concerning the confidentiality of your health information. You have the right:

* To request restrictions on the health information we may use and disclose for treatment, payment and health care
   operations. We are not required to agree to these requests. To request restrictions, please send a written request to us at
   the address below.
* To receive confidential communications of health information about you in any manner other than described in our
   authorization request form. You must make such requests in writing to the address below. However, we reserve the right
   to determine if we will be able to continue your treatment under such restrictive authorizations.
* To inspect or copy your health information. You must make such requests in writing to the address below. If you request
   a copy of your health information we may charge you a fee for the cost of copying, mailing or other supplies. In certain
   circumstances we may deny your request to inspect or copy your health information, subject to applicable law.
* To amend health information. If you feel that health information we have about you is incorrect or incomplete, you may
   ask us to amend the information. To request an amendment, you must write to us at the address below. You must also
   give us a reason to support your request. We may deny your request to amend your health information if it is not in
   writing or does not provide a reason to support your request. We may also deny your request if the health information:
       - was not created by us, unless the person that created the information is no longer available to make the amendment
       - is not part of the health information kept by or for us,
       - is not part of the information you would be permitted to inspect or copy, or
       - is accurate and complete.
* To receive an accounting of disclosures of your health information. You must make such requests in writing to the
   address below. Not all health information is subject to this request. Your request must state a time period for the
   information you would like to receive, no longer than 6 years prior to the date of your request and may not include dates
   before April 14, 2003. Your request must state how you would like to receive the report (paper, electronically).
* To designate another party to receive your health information. If your request for access of your health information
   directs us to transmit a copy of the health information directly to another person the request must be made by you in
   writing to the address below and must clearly identify the designated recipient and where to send the copy of the health
   information.

Complaints:

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or
to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you
make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax
or email shown above. If you prefer, you can discuss your complaint in person or by phone.

Changes to This Notice:

We reserve the right to change our privacy practices and to apply the revised practices to health information about you
that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted
prominently in our facility. Copies of this Notice are also available upon request at our reception area.

ACKNOWLEDGEMENT OF RECEIPT

I have been given the opportunity to read this practice's HIPPA Privacy Policies.*