Patient Forms

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:
City:		State/ZipCode

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer / School Name
Misc/Guardian

Is the Billing Address Different?

Insurance

Insurance Information

Insurance Name:
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:

Chief Complaints

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:

Eye History

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:

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:

Family Eye History

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

Medical History

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

Patient Medical History

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known 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? 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:

Social History

Hobbies:

STD's:

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

Race:

Ethnicity:

Preferred Language:

Review of Systems

Please choose from the menu options or select "OTHER" if you have a condition not listed. Thank you!

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

Policies, Consent and Submit Data

** Please click here to view our Notice of Privacy Practices **

Welcome to 20/20 Eyes Optometry

HIPAA- I have received a copy of 20/20 Eyes Optometry's 'Notice of Privacy Practices.
Enduring Permission and Authorization to Treat- I give permission and agree to any and all procedures/tests as part of medical/vision evaluation and/or treatment of the eyes or adnexa. I understand that evaluation/treatment has risk and may result in additional eye/systemic health issues and need for additional medical treatment. Examination, treatment may in onvolve use of medications which impair my vision and cause discomfort for several hours/days. I agree not to drive/operate machinery if I feel impaired in any way.
Contact Lens Risks- Lenses/products/inadequate care may cause eye irritation, infection, corneal injury, ulceration and permanent loss of vision. I agree to read and follow guidelines in "Risks, Care, Handling and Prescriptions for Contact Lenses". I am responsible for fees associated with treatment of contact lens related disease.
Lens Safety- I have been advised lens materials (such as polycarbonate) provide additional protection against shattering/eye injury and are recommended. Children under age 18 should have polycarbonate lenses. "Dress" frames fitted with polycarbonate lenses are not for safety use. Protective safety glasses with side shields or safety goggles should be used for all activities which have risk of ocular injury.
Smoking Risks- I know Smoking increases the risk of debilitating disease including eye disease.
UV Protection- I know ultraviolet exposure increases risk for eye disease over my lifetime. UV Protecting Lenses, sun wear of Photochromic lenses (transitions) are advised.
Patients Frame Waiver- I agree that this office, contracted lab delivery service and contracted optical laboratory are not responsible in any way for any breakage, damage and/or loss or frame(s) provided by me.
Warranty- I agree that frames and lenses are warranted by most manufacturers for 90 days against defects of workmanship. Any lens, frame or parts with such defect will be replaced or repaired at the manufacturers discretion. There is a nonrefundable charge to cover handling/shipping to the manufacturer. Manufacturers provide remediation (no refunds) which are industry standards for "failure to adapt". You are required to pay additional amounts for changes to more expensive lenses. For adaptation problems of prescriptions written and dispensed by Dr. Bich Tran, an office visit to recheck the prescription will be provided and new lenses will be made at no charge within 60 days or dispensing. Dr. Tran's prescriptions filled elsewhere are eligible for a prescription recheck, but we are not responsible for any charges incurred in remaking the lenses. Presciptions written by other doctors will be remade one time at no charge within 60 days with a new prescription.
Contact Lens Money Back Guarantee- Unopened/unmarked complete boxes of contact lenses dispensed by our office may be returned for refund up to 30 days after dispensing. Contact lens exam/management/training fees are not refundable.
Well Vision Exams- Vision plans supply well vision exams (routine health screening and vision correction). They do not cover medical diagnosis and/or treatment. I agree that my medical insurance may be billed if it is determined that medical examination/treatment is required.
Benefit Assignment- I authorize payment to 20/20 Eyes for benedits payable to me and release of information acquired in the course of my examination/treatment to insurance carrier(s), Medicare, or attorneys; this authorization shall be enduring and in effort for all my future visits/consulations until such time as I give further written notice. I agree that claims requiring my signature will be marked "Signature on File" and date of visit. I understand benefits are not a guarantee of payment by insurance/Medicare, and final determination is made by the insurer when the claim is processed. I am responsible for the balance of all fees, charges, copayments, deductibles, and denied/reversed claims. There is a $30 fee on all returned checks. I agree to be responsible for attorney/collection service(s) fees in event of defaults. Payment is due at the time of service. If fees collected at time of service are covered in full by insurance a refund of collected amounts will be forwarded to me when the account is completely paid.
I authorize and agree to all the above during the course of all my treatment(s).

Please check, sign, and date that you have read and agree to our policies and click the SUBMIT button to complete your online forms. Thank you!

Check:
Patient Signature:
Date:

City	State	ZipCode