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. Beaty OD, Melissa Dr. Follow ups, Walk Ins Dr. Wang OD, Lawrence	Misc/Guardian
Primary Care Doctor

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:

Vision Insurance 1

Insurance Information

Insurance Name:	None New Insurance A2 ABMS Advantica Adventist Risk Management ae Aetna Aetna Alaska ELectrical Health & Welfare Fund Altius Ameriben Ameritas Anthem Vision Armada Collections Assurant Health Avesis Bankers Life & Casualty BC/BS BC/BS Federal Employees Beech Street Corp. Benefit Administrators Benefit Planners Benicorp Brimhall Capitol Administrators Caremore CDS Group Health Cement & Concrete Workers Champva Chemical Lime Co.-Apex Plant Chesterfield Resources Inc Cigna Cigna International Clark County Self Funded Clearwater Paper Corporation Clovis Coast Benefits Coresource Coventry Crystal PM Culinary Custom Building Products Cypress Benefit dall Davis Definity Electrical Workers Eye Associates of Nevada Eye care Associates Eyeconic Eyemed First Health Fiserv Health Fiserv Health (Benefit Planners) GE Financial Geha General Atomics Gilsbar Golden Rule Great West Green Flag Collections Group Dental Insurance Plan Group Resources Guardian Health Market Insurance Company Health Partners Health Plan of Nevada Health Scope Health Smart HMA HMA INC Horseshoe (Binions) Humana IMX Insurance discount plan Jacobson MSO, Inc. JAS INC. John Alden Lions Club Loomis Lumenos Madison National Mail Handlers Major League Baseball Medben Medical Eye Services Medical Mutual Medicare Mediversal Meritain Health Misc. 1 Misc. 2 Moda Health Mutual of Omaha National Automatic Sprinkler Industry Nevada Care New Eyes New West Medicare No Insurance Operating Engineers Opticare Of Utah Other P5 Health Services Pabco Gypsum Painters Trust PBA PEN Medicare Claims Percs/Boyd Gaming PHCS philadelphia American Life Ins Comp Pinnacle Pipeline Industry Fund Plumber and Pipefitters Prime Silver State Principal Financial Priority Health Prominence Health First Providence Health Regence Reno Air Security Life Security Lilfe Senior Dimensions Sentinel Sierra Health Medical SIerrea Nevada Spectrum Silver State Medical South Point Benefits Southwest Carpenters Health and Welfare Spectera State Farm Medicare Supplement Station Casinos Sterling Options Summerlin Life & Health Superior Vision Teachers Health Trust Teamsters Montana Teamsters Security Fund The Loomis Company Tricare True BLue Twin City Optical U.S. Safety UHC Military services UMR United American Insurance United Brotherhood of Carpenters United Health Care Universal Health Care Universal Health Network UPRR Health Services Vision Benefits of America Vision Care Advantage Vision One(Discount Only) Vision Service Plan (VSP) Wellish Wellish Co-Manage Wells Fargo Third Party Admin. Wisconsin Electrical Health & Welfare WMI/TPA Workers Comp-Liberty Mutual Insurance Company
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:

Vision Insurance 2

Insurance Information

Insurance Name:	None New Insurance A2 ABMS Advantica Adventist Risk Management ae Aetna Aetna Alaska ELectrical Health & Welfare Fund Altius Ameriben Ameritas Anthem Vision Armada Collections Assurant Health Avesis Bankers Life & Casualty BC/BS BC/BS Federal Employees Beech Street Corp. Benefit Administrators Benefit Planners Benicorp Brimhall Capitol Administrators Caremore CDS Group Health Cement & Concrete Workers Champva Chemical Lime Co.-Apex Plant Chesterfield Resources Inc Cigna Cigna International Clark County Self Funded Clearwater Paper Corporation Clovis Coast Benefits Coresource Coventry Crystal PM Culinary Custom Building Products Cypress Benefit dall Davis Definity Electrical Workers Eye Associates of Nevada Eye care Associates Eyeconic Eyemed First Health Fiserv Health Fiserv Health (Benefit Planners) GE Financial Geha General Atomics Gilsbar Golden Rule Great West Green Flag Collections Group Dental Insurance Plan Group Resources Guardian Health Market Insurance Company Health Partners Health Plan of Nevada Health Scope Health Smart HMA HMA INC Horseshoe (Binions) Humana IMX Insurance discount plan Jacobson MSO, Inc. JAS INC. John Alden Lions Club Loomis Lumenos Madison National Mail Handlers Major League Baseball Medben Medical Eye Services Medical Mutual Medicare Mediversal Meritain Health Misc. 1 Misc. 2 Moda Health Mutual of Omaha National Automatic Sprinkler Industry Nevada Care New Eyes New West Medicare No Insurance Operating Engineers Opticare Of Utah Other P5 Health Services Pabco Gypsum Painters Trust PBA PEN Medicare Claims Percs/Boyd Gaming PHCS philadelphia American Life Ins Comp Pinnacle Pipeline Industry Fund Plumber and Pipefitters Prime Silver State Principal Financial Priority Health Prominence Health First Providence Health Regence Reno Air Security Life Security Lilfe Senior Dimensions Sentinel Sierra Health Medical SIerrea Nevada Spectrum Silver State Medical South Point Benefits Southwest Carpenters Health and Welfare Spectera State Farm Medicare Supplement Station Casinos Sterling Options Summerlin Life & Health Superior Vision Teachers Health Trust Teamsters Montana Teamsters Security Fund The Loomis Company Tricare True BLue Twin City Optical U.S. Safety UHC Military services UMR United American Insurance United Brotherhood of Carpenters United Health Care Universal Health Care Universal Health Network UPRR Health Services Vision Benefits of America Vision Care Advantage Vision One(Discount Only) Vision Service Plan (VSP) Wellish Wellish Co-Manage Wells Fargo Third Party Admin. Wisconsin Electrical Health & Welfare WMI/TPA Workers Comp-Liberty Mutual Insurance Company
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:

Vision Insurance 3

Insurance Information

Insurance Name:	None New Insurance A2 ABMS Advantica Adventist Risk Management ae Aetna Aetna Alaska ELectrical Health & Welfare Fund Altius Ameriben Ameritas Anthem Vision Armada Collections Assurant Health Avesis Bankers Life & Casualty BC/BS BC/BS Federal Employees Beech Street Corp. Benefit Administrators Benefit Planners Benicorp Brimhall Capitol Administrators Caremore CDS Group Health Cement & Concrete Workers Champva Chemical Lime Co.-Apex Plant Chesterfield Resources Inc Cigna Cigna International Clark County Self Funded Clearwater Paper Corporation Clovis Coast Benefits Coresource Coventry Crystal PM Culinary Custom Building Products Cypress Benefit dall Davis Definity Electrical Workers Eye Associates of Nevada Eye care Associates Eyeconic Eyemed First Health Fiserv Health Fiserv Health (Benefit Planners) GE Financial Geha General Atomics Gilsbar Golden Rule Great West Green Flag Collections Group Dental Insurance Plan Group Resources Guardian Health Market Insurance Company Health Partners Health Plan of Nevada Health Scope Health Smart HMA HMA INC Horseshoe (Binions) Humana IMX Insurance discount plan Jacobson MSO, Inc. JAS INC. John Alden Lions Club Loomis Lumenos Madison National Mail Handlers Major League Baseball Medben Medical Eye Services Medical Mutual Medicare Mediversal Meritain Health Misc. 1 Misc. 2 Moda Health Mutual of Omaha National Automatic Sprinkler Industry Nevada Care New Eyes New West Medicare No Insurance Operating Engineers Opticare Of Utah Other P5 Health Services Pabco Gypsum Painters Trust PBA PEN Medicare Claims Percs/Boyd Gaming PHCS philadelphia American Life Ins Comp Pinnacle Pipeline Industry Fund Plumber and Pipefitters Prime Silver State Principal Financial Priority Health Prominence Health First Providence Health Regence Reno Air Security Life Security Lilfe Senior Dimensions Sentinel Sierra Health Medical SIerrea Nevada Spectrum Silver State Medical South Point Benefits Southwest Carpenters Health and Welfare Spectera State Farm Medicare Supplement Station Casinos Sterling Options Summerlin Life & Health Superior Vision Teachers Health Trust Teamsters Montana Teamsters Security Fund The Loomis Company Tricare True BLue Twin City Optical U.S. Safety UHC Military services UMR United American Insurance United Brotherhood of Carpenters United Health Care Universal Health Care Universal Health Network UPRR Health Services Vision Benefits of America Vision Care Advantage Vision One(Discount Only) Vision Service Plan (VSP) Wellish Wellish Co-Manage Wells Fargo Third Party Admin. Wisconsin Electrical Health & Welfare WMI/TPA Workers Comp-Liberty Mutual Insurance Company
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 Insurance 1

Insurance Information

Insurance Name:	None New Insurance A2 ABMS Advantica Adventist Risk Management ae Aetna Aetna Alaska ELectrical Health & Welfare Fund Altius Ameriben Ameritas Anthem Vision Armada Collections Assurant Health Avesis Bankers Life & Casualty BC/BS BC/BS Federal Employees Beech Street Corp. Benefit Administrators Benefit Planners Benicorp Brimhall Capitol Administrators Caremore CDS Group Health Cement & Concrete Workers Champva Chemical Lime Co.-Apex Plant Chesterfield Resources Inc Cigna Cigna International Clark County Self Funded Clearwater Paper Corporation Clovis Coast Benefits Coresource Coventry Crystal PM Culinary Custom Building Products Cypress Benefit dall Davis Definity Electrical Workers Eye Associates of Nevada Eye care Associates Eyeconic Eyemed First Health Fiserv Health Fiserv Health (Benefit Planners) GE Financial Geha General Atomics Gilsbar Golden Rule Great West Green Flag Collections Group Dental Insurance Plan Group Resources Guardian Health Market Insurance Company Health Partners Health Plan of Nevada Health Scope Health Smart HMA HMA INC Horseshoe (Binions) Humana IMX Insurance discount plan Jacobson MSO, Inc. JAS INC. John Alden Lions Club Loomis Lumenos Madison National Mail Handlers Major League Baseball Medben Medical Eye Services Medical Mutual Medicare Mediversal Meritain Health Misc. 1 Misc. 2 Moda Health Mutual of Omaha National Automatic Sprinkler Industry Nevada Care New Eyes New West Medicare No Insurance Operating Engineers Opticare Of Utah Other P5 Health Services Pabco Gypsum Painters Trust PBA PEN Medicare Claims Percs/Boyd Gaming PHCS philadelphia American Life Ins Comp Pinnacle Pipeline Industry Fund Plumber and Pipefitters Prime Silver State Principal Financial Priority Health Prominence Health First Providence Health Regence Reno Air Security Life Security Lilfe Senior Dimensions Sentinel Sierra Health Medical SIerrea Nevada Spectrum Silver State Medical South Point Benefits Southwest Carpenters Health and Welfare Spectera State Farm Medicare Supplement Station Casinos Sterling Options Summerlin Life & Health Superior Vision Teachers Health Trust Teamsters Montana Teamsters Security Fund The Loomis Company Tricare True BLue Twin City Optical U.S. Safety UHC Military services UMR United American Insurance United Brotherhood of Carpenters United Health Care Universal Health Care Universal Health Network UPRR Health Services Vision Benefits of America Vision Care Advantage Vision One(Discount Only) Vision Service Plan (VSP) Wellish Wellish Co-Manage Wells Fargo Third Party Admin. Wisconsin Electrical Health & Welfare WMI/TPA Workers Comp-Liberty Mutual Insurance Company
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 Insurance 2

Insurance Information

Insurance Name:	None New Insurance A2 ABMS Advantica Adventist Risk Management ae Aetna Aetna Alaska ELectrical Health & Welfare Fund Altius Ameriben Ameritas Anthem Vision Armada Collections Assurant Health Avesis Bankers Life & Casualty BC/BS BC/BS Federal Employees Beech Street Corp. Benefit Administrators Benefit Planners Benicorp Brimhall Capitol Administrators Caremore CDS Group Health Cement & Concrete Workers Champva Chemical Lime Co.-Apex Plant Chesterfield Resources Inc Cigna Cigna International Clark County Self Funded Clearwater Paper Corporation Clovis Coast Benefits Coresource Coventry Crystal PM Culinary Custom Building Products Cypress Benefit dall Davis Definity Electrical Workers Eye Associates of Nevada Eye care Associates Eyeconic Eyemed First Health Fiserv Health Fiserv Health (Benefit Planners) GE Financial Geha General Atomics Gilsbar Golden Rule Great West Green Flag Collections Group Dental Insurance Plan Group Resources Guardian Health Market Insurance Company Health Partners Health Plan of Nevada Health Scope Health Smart HMA HMA INC Horseshoe (Binions) Humana IMX Insurance discount plan Jacobson MSO, Inc. JAS INC. John Alden Lions Club Loomis Lumenos Madison National Mail Handlers Major League Baseball Medben Medical Eye Services Medical Mutual Medicare Mediversal Meritain Health Misc. 1 Misc. 2 Moda Health Mutual of Omaha National Automatic Sprinkler Industry Nevada Care New Eyes New West Medicare No Insurance Operating Engineers Opticare Of Utah Other P5 Health Services Pabco Gypsum Painters Trust PBA PEN Medicare Claims Percs/Boyd Gaming PHCS philadelphia American Life Ins Comp Pinnacle Pipeline Industry Fund Plumber and Pipefitters Prime Silver State Principal Financial Priority Health Prominence Health First Providence Health Regence Reno Air Security Life Security Lilfe Senior Dimensions Sentinel Sierra Health Medical SIerrea Nevada Spectrum Silver State Medical South Point Benefits Southwest Carpenters Health and Welfare Spectera State Farm Medicare Supplement Station Casinos Sterling Options Summerlin Life & Health Superior Vision Teachers Health Trust Teamsters Montana Teamsters Security Fund The Loomis Company Tricare True BLue Twin City Optical U.S. Safety UHC Military services UMR United American Insurance United Brotherhood of Carpenters United Health Care Universal Health Care Universal Health Network UPRR Health Services Vision Benefits of America Vision Care Advantage Vision One(Discount Only) Vision Service Plan (VSP) Wellish Wellish Co-Manage Wells Fargo Third Party Admin. Wisconsin Electrical Health & Welfare WMI/TPA Workers Comp-Liberty Mutual Insurance Company
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:

Privacy Policy

Privacy Policy

Privacy Policy NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. We reserve the right to change to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before the changes. In the event we make an important change in our privacy practices, we will change this notice and make the new notice available upon request. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to doctors, nurses, technicians, medical students, or other people who are taking care of you for :(a) the provision, coordination, or management of health care and related services by health care providers; (b) consultation between health care providers relating to a patient; (c) the referral of a patient for health care from one health care provider to another; or (d) recall information. Payment: We may use and disclose your health information to obtain payment for services we provide to you. This may include: (a) billing and collection activities and related data processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews, utilization review activities, and (d) disclosure to consumer reporting agencies of information relating to collection of premiums or reimbursement. Health Care Operations: We may use and disclose your health information in connection with our healthcare operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certification, licenses and credentials we need to serve you. Marketing Health Care Products or Services: We will not use your health information for marketing communications without your prior written authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will never sell your health care information. To Family and Friends: We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or payment for your healthcare, if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Required By Law: We may use or disclose your health information when we are required to do so by law, including judicial and administrative proceedings. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. Appointment Reminders & Treatment Alternatives: We may use or disclose your health information to provide you with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. PATIENT RIGHTS Access: You have the right to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make your request in writing. You may get the form to request access by using the contact information listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the end of this notice. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you request copies we will charge you $ 0.50 for each page, and postage if you want the copies mailed to you. Contact us using the information listed at the end of this notice for a full explanation of our fee structure. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and other specified exceptions. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. Electronic Notice: If you receive this notice on our Web site or by e-mail and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the Privacy Officer at our office. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information you may complain to us using the contact information listed at the end of this notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint. Contact Person: Lawrence Wang, O.D. - Privacy Officer Telephone: 702-220-3937 Fax: 702-655-3182 Address: 7090 N. Durango Blvd. #110, Las Vegas, NV 89149 I have read and understood the Centennial Family Eyecare Privacy Policy. >

Enhanced Testing

Advanced Testing

I would like an advanced digital retinal photogrpaph ($39) that helps the doctor detect early eye disease? (yes or no)

I would like to be screened by our skin caratenoid bioscanner to measure macular degeneration risk? ($30)(yes or no)

I would like a high definition OCT ultrasound of your optic nerves to measure glaucoma risk? ($30) Yes or No

Medical History

Welcome to Centennial Family Eyecare: Dr. Lawrence Wang & Associates

Today's Date

Where was your last eye exam?

When was your last eye exam?

1 year 2 years 3 years >4 years >10 years >15 years >20 years Other

What is your Occupation?

engineer food server nurse pilot Retired Stay at Home Mother Student teacher Other

Do you have any hobbies?

Crafts Fishing Golf Music Reading Sewing Shooting Sports Other

What is your preferred Nickname?

Patient since:

What is your Date of Birth:

Is there any eye disease in the family?:

Ethnicity:

White Hispanic or Latino Asian Black or African American American Indian or Alaska Native Native Hawaiian or Pacific Islander (Declined) Other

Prefered Language

English Spanish (Declined) Other

Primary Care Physician & Other physician Names

What is the purpose of your visit today?

GL Exam CL Exam Eye Health Check Diabeteic Exam DMV Test Eye Injury Failed School Screener First Eye Exam First Time CL Wear Hypertension Exam Work Requirement ----------FOLLOW UP---------- CL f/u from: Red eye f/u from: Cataract Post Op CL f/u, first time CL wear on: CL fit DFE Dry eye f/u Fundus Photo GL Rx re-check from: IOP ck Medical f/u VF repeat Follow up

Do you have any Secondary Complaints?

None GL Update CL Update Interested in CLs Eye Health Check Diabeteic Exam DMV Test Eye Injury Failed School Screener First Eye Exam First Time CL Wear Hypertension Exam Work Requirement ----------FOLLOW UP---------- CL f/u from: Red eye f/u from: Medical f/u Dry eye f/u IOP ck Cataract Post Op CL fit DFE Fundus Photo GL Rx re-check from: VF repeat Follow up ----------CONCERNS---------- Concern of Amblyopia Concern of Cataracts Concern of Diabetes Concern of Glaucoma Concern of Hypertension Concern of Keratoconus Concern of Macular Degeneration Concern of Nevus Concern of Retinal Health ----------SYMPTOMS---------- No VA Concerns Blurred Vision Distance Blur Near Blur Intermediate Blur Sudden Loss of Vision CL Discomfort Glare Ache Burning Sensation Crustie Curtain Effect Distorted Vision Double VIsion Dryness Eye Turn Flashes of Light Floaters Foreign Body Sensation Haze/Mist Haloes Headaches Irritation Itchiness Keratoconus Lid Mass Lids stuck together in AM Mattering Pain Redness Stinging Tearing Tired/Fatigue Watery Other

What is your contact lens history?

Have you had any Eye Surgeries?

None Blepharoplasty IOL OD IOL OS IOL OU Lasik Dist. OU Lasik Mono Lasik OD Lasik OS RD Laser RD Repair Scleral Buckle OD Scleral Buckle OS Scleral Buckle OU Vitrectomy Other

Other Surgeries:

Do you have any drug allergies?

What Medications are you taking?

Allergy Cholesterol Diabetes Heart HTN Thyroid Other

What Other medications are you taking?

Who Referred you today?

I have read and understood the Centennial Family Eyecare Privacy Policy.

I would like to receive text messages from Centennial Family Eyecare. Phone Number:

The following person(s) are allowed to pick up my prescriptions and materials. Name & Phone Number:

Submit Data