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 Pronoun
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



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

Submit Data / Patient Signatures



AUTHORIZE RELEASE OF INFORMATION

Please list anyone authorized to discuss your medical and/or financial records with us.

Name:  Click One Or Both
MedicalFinancial
MedicalFinancial
MedicalFinancial


RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I received the Notice of Privacy Practices from LOOK Eyecare & Eyewear, which sets forth the ways in which my personal health information may be used or disclosed and outlines my rights with respect to such information. You have the right to refuse or revoke this authorization, in writing, at any time.

Patient Name (Print): Guardian Name (Print):

Patient/Guardian Signature: Date:

ASSIGNMENT OF BENEFITS

Vision Insurance

Insurance Company: ID# Group#
Primary Insured's Name: Date Of Birth
Patient's relationship to Primary Insured: Spouse / Partner Child Other

Primary Medical Insurance

Insurance Company: ID# Group#
Primary Insured's Name: Date Of Birth
Patient's relationship to Primary Insured: Spouse / Partner Child Other

Secondary Medical Insurance

Insurance Company: ID# Group#
Primary Insured's Name: Date Of Birth
Patient's relationship to Primary Insured: Spouse / Partner Child Other

*If you do not know your ID# it may be the primary insured's SSN


Assignment of Benefits

I assign all insurance benefits and authorize my insurance carriers(s) listed above, to issue payment directly to LOOK Eyecare & Eyewear for services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance.

Authorization to Release Information

I authorize LOOK Eyecare & Eyewear to release any information necessary to insurance carriers regarding my eye care and process insurance claims generated in the course of examination or treatment. This order will remain in effect until revoked by me in writing.

Financial Responsibility

I have requested medical services from LOOK Eyecare & Eyewear on behalf of myself or my dependents, and understand that by making this request, I became fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

Patient Name (Print): Guardian Name (Print):

Patient/Guardian Signature: Date:

Missed and Late Appointment Policies

To respect the time of our scheduled patients, our office has the following policies in place:

  • An appointment is considered a "No-Show" if.

    •       • It is canceled or rescheduled less than 1 hour before the scheduled time
          • You arrive more than 15 minutes late to your scheduled appointment
          • The appointment is missed entirely
          • If you have an appointment and choose to reschedule online without notifying the office. You will have to sign this waiver.

  • One "No-show" will be allowed without penalty (life happens, we understand)

  • After one "No-show" we will require a $25.00 "No-show" charge. You will not be able to reschedule until the payment is taken.

  • If you "No-show" on Saturday you will no longer be able to schedule on a Saturday.

    • These policies will allow us to give each patient our undivided attention and the best experience possible.

    Thank you for understanding.

    Sincerely,

    LOOK Eyecare & Eyewear


    By Signing, you acknowledge that you have read and consent to the above policy.

    Patient/Guardian Signature: Date:

    Contact Lens Fitting

    Each year the Doctor per FDA is required to evaluate your cornea (the transparent layer forming the front of the eye) to look for any changes that may have occurred such as adjustments of contact brands, materials, and/or prescriptions.

    Most vision plans will cover or have a discount for contact fee. We will let you know at the time of services.

  • New Wearer: $100.00

    • This includes

          • The fitting
          • Training on how to inserting/remove your contacts
          • Follow up visit for 90 days to confirm prescription and the fit is right for you

  • Current Wearer: $75.00

    • This includes

          • Revaluation of cornea
          • Prescription
          • Follow up visits for 90 days


    FOR CONTACT WEARER ONLY: Please sign and date the form.

    Patient/Guardian Signature: Date: