Parent Morris Eyecare Logo

Online Patient Form

Click here to return to the previous website.

After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

(Please note: Completing this form is for submission of medical health history ONLY. If you are interested in scheduling an appointment, please call our office at 479.636.1960.)

Patient Information


TitleFirstLastMISuffixNicknamePronoun
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Birth Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address Different?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
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!

Eye History

Reason for Visit:
Primary Reasons: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: Last Appointment Type By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Medical History

Medications: Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot: Recent Flu Immunization:


Do you have any of these medical conditions?:

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

Family Medical History



Does anyone in your family have any of these medical conditions?:

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

Family Eye History

Does anyone in your family have any of these eye conditions?:

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Blindness:

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:

Social History

Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:
STD

Patient Signature Forms

Acknowledgment of Notice of Privacy Practices

The law requires that Parenti Morris Eye Care, PLLC make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:

I was given the opportunity to read, have read or had explained to me Parenti Morris Eye Care, PLLC's Notice of Privacy Practice prior to any services offered.

The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible

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

Patient Signature: Date:

If you are signing as a personal representative of the patient, please indicate your relationship

Representative Signature: Relationship to Patient:

Patient- Authorized Representatives

I authorize Parenti-Morris Eyecare to discuss and/or release my medical information including test results, diagnosis, payment and treatments discussed to the following persons:

Name: Relationship:

Name: Relationship:

Name: Relationship:
NONE

I understand that I have the right to revoke/modify this authorization at any time.

Patient or Legal Guardian Signature: Date:

Authorization/Non-Parent/Guardian to Accompany Patient

At Parenti Morris we know there may be times when you are unable to bring your child to the office for an appointment and need to rely on a family member or friend. We understand these circumstances; however, we must have a written authorization letter allowing this person to accompany your child(ren). The person brining your child will need to present a photo identification at time of service.

Child's Name: D.O.B

Child's Name: D.O.B

Child's Name: D.O.B

This Authorization gives the person permission to bring your child(ren) in, speak to the Doctor, and give Authorization for treatment.

I give person(s) listed below permission to bring my child(ren) to Parenti Morris Eyecare and to discuss and share information about my child.

Name of Person Allowed to Bring Child

Name: Relationship:

Name: Relationship:

Parent or Legal Guardian Signature Date

Minor Consent Form

I, , parent /legal guardian of , hereby give permission for Parenti Morris eyecare to examine my son/daughter without my presence. I understand that I am responsible for providing any necessary information regarding insurance coverage and I accept responsibility for any services and fees rendered that are not covered by my insurance.
In case of Emergency, I can be contacted at:

Signature
Relationship to Patient
Date

Finished! Please hit the Submit button below.