Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr.

Address
City:		State/ZipCode	NV CA

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. Corbit-Drakulich, Janet Dr. Steyn, Lori	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr.

Address

City	State	ZipCode
	NV CA

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP AETNA ANTHEM BLUE VIEW VISION ASR Health Benefits ASR HEALTH BENEFITS ASSURANT HEALTH BCBS OF NEVADA CDS CIGNA DEPARTMENT OF VETERAN AFFAIRS HEALTH ADMINISTRATION CENTER EQUITABLE LIFE CASUALTY EYEMED GEHA GOLDEN RULE INSURANCE COMPANY GREAT WEST HEALTHCARE HCC HEALTH COMP Health First HEALTH SCOPE HOMETOWN HEALTH - II HOMETOWN HEALTH - NV HOMETOWN HEALTH - TX HUMANA MEDICAID MEDICARE PART B MEDICO MUTUAL OF OMAHA PENNSYLVANIA LIFE INSURANCE CO. Prominence SAINT MARY'S PREFERRED HEALTHCARE SELF PAY SENIOR CARE PLUS SENIOR DIMENSIONS SIERRA HEALTH & LIFE SIERRA NEVADA SPECTRUM ST. MARY'S PHC STANDARD LIFE STERLING INVESTORS LIFE INSURANCE SUPERIOR VISION SERVICES INC TEAMSTERS BENEFIT TRUST THE EMPLOYEE PAINTERS' TRUST HEALTH & WELFARE PLAN THE MAIL HANDLERS BENEFIT THE MAIL HANDLERS BENEFIT PLAN THRIVENT FINACIAL FOR LUTHERANS TIME INSURANCE COMPANY TRICARE TRICARE WEST REGIONS CLAIMS UFCW UNIONS & FOOD EMPLOYERS FUND UMR UMR / UNITED HEALTH CARE UNI CARE UNITED AMERICAN UNITED COMMERCIAL TRAVELERS UNITED HEALTH CARE UNITED HEALTH CARE ALLIES UNITED HEALTH CARE CHOICE PLUS UNIVERSAL HEALTH NETWORK Unknown Import US Family Health Plan VETERANS ADMINISTRATION HEALTH CARE SYSTEM VISION SERVICE PLAN WELLS FARGO INSURANCE SERVICES
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:

Secondary

Insurance Information

Insurance Name:	None AARP AETNA ANTHEM BLUE VIEW VISION ASR Health Benefits ASR HEALTH BENEFITS ASSURANT HEALTH BCBS OF NEVADA CDS CIGNA DEPARTMENT OF VETERAN AFFAIRS HEALTH ADMINISTRATION CENTER EQUITABLE LIFE CASUALTY EYEMED GEHA GOLDEN RULE INSURANCE COMPANY GREAT WEST HEALTHCARE HCC HEALTH COMP Health First HEALTH SCOPE HOMETOWN HEALTH - II HOMETOWN HEALTH - NV HOMETOWN HEALTH - TX HUMANA MEDICAID MEDICARE PART B MEDICO MUTUAL OF OMAHA PENNSYLVANIA LIFE INSURANCE CO. Prominence SAINT MARY'S PREFERRED HEALTHCARE SELF PAY SENIOR CARE PLUS SENIOR DIMENSIONS SIERRA HEALTH & LIFE SIERRA NEVADA SPECTRUM ST. MARY'S PHC STANDARD LIFE STERLING INVESTORS LIFE INSURANCE SUPERIOR VISION SERVICES INC TEAMSTERS BENEFIT TRUST THE EMPLOYEE PAINTERS' TRUST HEALTH & WELFARE PLAN THE MAIL HANDLERS BENEFIT THE MAIL HANDLERS BENEFIT PLAN THRIVENT FINACIAL FOR LUTHERANS TIME INSURANCE COMPANY TRICARE TRICARE WEST REGIONS CLAIMS UFCW UNIONS & FOOD EMPLOYERS FUND UMR UMR / UNITED HEALTH CARE UNI CARE UNITED AMERICAN UNITED COMMERCIAL TRAVELERS UNITED HEALTH CARE UNITED HEALTH CARE ALLIES UNITED HEALTH CARE CHOICE PLUS UNIVERSAL HEALTH NETWORK Unknown Import US Family Health Plan VETERANS ADMINISTRATION HEALTH CARE SYSTEM VISION SERVICE PLAN WELLS FARGO INSURANCE SERVICES
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:

Tertiary

Insurance Information

Insurance Name:	None AARP AETNA ANTHEM BLUE VIEW VISION ASR Health Benefits ASR HEALTH BENEFITS ASSURANT HEALTH BCBS OF NEVADA CDS CIGNA DEPARTMENT OF VETERAN AFFAIRS HEALTH ADMINISTRATION CENTER EQUITABLE LIFE CASUALTY EYEMED GEHA GOLDEN RULE INSURANCE COMPANY GREAT WEST HEALTHCARE HCC HEALTH COMP Health First HEALTH SCOPE HOMETOWN HEALTH - II HOMETOWN HEALTH - NV HOMETOWN HEALTH - TX HUMANA MEDICAID MEDICARE PART B MEDICO MUTUAL OF OMAHA PENNSYLVANIA LIFE INSURANCE CO. Prominence SAINT MARY'S PREFERRED HEALTHCARE SELF PAY SENIOR CARE PLUS SENIOR DIMENSIONS SIERRA HEALTH & LIFE SIERRA NEVADA SPECTRUM ST. MARY'S PHC STANDARD LIFE STERLING INVESTORS LIFE INSURANCE SUPERIOR VISION SERVICES INC TEAMSTERS BENEFIT TRUST THE EMPLOYEE PAINTERS' TRUST HEALTH & WELFARE PLAN THE MAIL HANDLERS BENEFIT THE MAIL HANDLERS BENEFIT PLAN THRIVENT FINACIAL FOR LUTHERANS TIME INSURANCE COMPANY TRICARE TRICARE WEST REGIONS CLAIMS UFCW UNIONS & FOOD EMPLOYERS FUND UMR UMR / UNITED HEALTH CARE UNI CARE UNITED AMERICAN UNITED COMMERCIAL TRAVELERS UNITED HEALTH CARE UNITED HEALTH CARE ALLIES UNITED HEALTH CARE CHOICE PLUS UNIVERSAL HEALTH NETWORK Unknown Import US Family Health Plan VETERANS ADMINISTRATION HEALTH CARE SYSTEM VISION SERVICE PLAN WELLS FARGO INSURANCE SERVICES
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 History

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

Reason for Visit:

none Glasses Contacts Glasses and Contacts Other

Interested in LASIK?	N/A Yes No Other
Your Last Eye Exam:		Name of Clinic/Doctor:	none Other

What do you wear?:

none glasses contacts neither both Other

What are they for?

n/a distance near both Other

Occupation/Hobby:

Have you ever had:

Eye Injuries:	None Yes No Other
Eye Surgery:	None Cataract Surgery LASIK Other
Eye Infections:	None Pink Eye Corneal Ulcer Other

Do you or does anyone in your immediate family have any of the following?

Glaucoma	Who? None You Mother Father Sibling Grandparent Other	Diabetes	Who? None You Mother Father Sibling Grandparent Other
Blindness	Who? None You Mother Father Sibling Grandparent Other	Macular Degeneration	Who? None You Mother Father Sibling Grandparent Other
Lazy Eye	Who? None You Mother Father Sibling Grandparent Other	High Blood Pressure	Who? None You Mother Father Sibling Grandparent Other
Eye Turn	Who? None You Mother Father Sibling Grandparent Other	Thyroid disorder	Who? None You Mother Father Sibling Grandparent Other
Arthritis	Who? None You Mother Father Sibling Grandparent Other	Migraines	Who? None You Mother Father Sibling Grandparent Other
Cancer	Who? None You Mother Father Sibling Grandparent Other	Other:

Last medical exam:

Physician:

List all Medications: None	Major Surgeries/Illnesses:

Medicine Allergies:

None Erythromycin Iodine Pollen Penicillin PCN Sulfa Codeine Tetanus Other No Known Drug Allergies

Do you currently, or have you ever had, any problems in the following areas:

Allergic/Immunologic:	None Hay Fever Allergies Other
Bones, Joints, Muscles:	None Arthritis Muscle/Joint Pain Osteoarthritis Osteoporosis Rheumatoid Arthritis Swollen Joints Other
Cardiovascular:	None Atrial Fibrillation Bypass Chest Pain Circulatory or Vascular Disease Heart Problems High Blood Pressure High Cholesterol Stroke Other
Constitutional(Current):	None Fatigue Fever Unexplained Weight Change Other
Ears, Nose, Throat:	None Chronic Cough Dry Mouth Runny Nose Sinus Congestion Other
Endocrine:	None Diabetes Hashimoto's Disease Neck Pain Other Glands Thyroid Other
Gastrointestinal	None Abdominal Pain Acid Reflex Gerd Heartburn Recurrent Diarrhea Ulcer Other
Genitourinary:	None Genitals Kidney or Bladder Problems Other
Integumentary (Skin):	None Cancer Eczema Excessive Dryness Itching Psoriasis Rashes Other
Lymphatic/Hematologic:	None Anemia Blood Disorders Bleeding Problems Other
Nervous System:	None Dizziness Headaches Migraines Motion Sickness Multiple Sclerosis Numbness Paralysis Seizures Weakness Multiple Sclerosis Other
Psychiatric:	None ADHD Anxiety Depression Special Needs Other
Respiratory:	None Asthma Chronic Bronchitis COPD Coughing Emphysema Shortness of Breath Sleep Apnea Wheezing Other
Eyes	None Itching Burning Excess Tearing Redness Sandy/Gritty Feeling Dryness Mucus Discharge Glare/Light Sensitivity Eye Pain/Soreness Chronic Infection Sties Flashes of Light Floaters Distorted Vision/Halos Blurred Vision Loss of Vision Double Vision Tired Eyes Eye Strain with Computers Poor Night Vision Poor Depth Perception Low Reading Comprehension Other
Other:	None Cancer Other

Do you:

Use Tobacco

Drink Alcohol

Use Recreational/Illicit Drugs

None

Smoking Status

Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other

If Yes, Type, Freq, Amount, Duration:

none Other

Any History Of:

None HIV Gonorrhea Hepatitis Syphilis Other

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