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15550 Ranch Road 620 N • Suite 100 • Austin, Texas 78717
512.251.4040
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Patient Information
Title
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Mrs.
Ms.
Dr.
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Last
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SSN
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Employment Status
Employed
Full-Time Student
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Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
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Polygamous
Widowed
Employer / School Name
Doctor Preference
No Doctor Assigned
Dr. Hamilton O.D., Derek
Dr. Pushpam, Baweja
Misc/Guardian
Primary Care Doctor
Billing Information
Is The Billing Address the Same?
Yes
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
First Name
Last Name
MI
Suffix
Street Address
City
State
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
Zip
Home Phone
Work Phone
Primary
Insurance Information
Insurance Name
None
AARP
Acordia Benefits Of Texas,Inc.
Aetna
Aetna Better Health
AFLAC
AIDS Services Of Austin
AISD Vision & Hearing Screening Program
Allegiance Benefit Plan Management, Inc.
Allied Benefit Systems
Allsup Inc
Amerigroup
Ameritas
Assurant Health
Assured Benefits Administrator
Austin Lion's Club
Avesis
Beech Street
Benefit Planners, Inc.
Block Vision
Blue Cross And Blue Shield
Blue Cross and Blue Shield of North Dakota
Care Improvement Plus
CBA
CHAMPVA
Cigna Health Care
Coast-to-Coast Discount Plan
Cole Managed Vision Care
CommUnityCare
Corporate Benefit Services of America
Davis Vision
Dell Laser Consultants
Department of Veterans Affairs
Emblem Health
envolve Benefit Options
Excellus Benefit Services
Eye LASIK Austin
EyeMed Vision Care
Eyetopia Vision Care
Fallon Health & Life Assurance Company
First Health
FiServ
Foundation for the Homeless
GEHA
General American
Great West Health Plans
Group Administrators, Ltd.
Group and Pension Administrators
Group Health Incorporated
Guardian
Harvard Pilgrim Health Care
HealthFirst Third Party Administrators
HealthPartners
HealthSmart
Heraeus Amersil Inc
HRA/HSA Account
HRHG Benefits Services, Inc.
Humana
Insurance Management Administrators
Johnson and Johnson
LifeRe Insurance Company
Loyal American Life Insurance Company
Lumenos
Medicaid - Block Vision
Medicaid - Opticare
Medicaid - Traditional
Medicare
Medicare Palmetto G.B.A.
Medicare Supplement
MEDIPLUS
Meritain Health
Metropolitan Life
Miscellaneous
MPE Employee Benefit Services Inc.
MultiPlan
Mutual Assurance Administrators
Mutual of Omaha
No Insurance
None
Nueva Vida Iglesia
OneHealthPlan
Opticare
PALMETTO GBA - RAILROAD MEDICARE
Pflugerville Lions Club
PHCS
Phoenix Group Services
Physicians Health Choice
Preferred Care
Prevent Blindness
Principal Life Insurance Company
Railroad Medicare
Red Cross
Reliance Standard Life Ins Co
Risk Management Services
RMSCO
RSL Specialty Products Administration
Rural Carrier Benefit Plan
Scott & White Health Plan
Spectera/Optum Health
State Farm
Superior Vision Services, Inc.
Texas Commission For The Blind
Texas Community Care
Texas Diabetic Eye Disease Program
Texas Disability Determination Services
Texas True Choice
The Epoch Group, L.C.
Thrivent Financial for Lutherans
TLC Laser Center
TML Intergov Emp Benefits Pool
Tower Life Insurance Company
TRICARE
UMR
Unicare
United Health Allies Discount Plan
United Health Care
United of Omaha
Vision Care Plan
Vision Service Plan
Vision USA
WellMed
Workmen's Comp
XX1Contacts.com
xxPrincipal Financial Group
Z Aetna
Z Blue Cross Of Idaho
Z Bluecross Blueshield - Oregon
Z DMI Document Retrieval, Inc.
Z Mann Berkley Caplan Laser Cntr
Z National Heritage Insurance Co
Z New Horizon's Vision Center
Z Omaha Health Care Service Cntr
Z PCA/Local Office
Z PCA/VSP
Z Prucare
Z VSP - Arizona
ZGeneral American
ZProfessional Vision Care
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
Street Address
City
State
Zip
Phone Number
Birthday
SSN
Employer/School
Secondary
Insurance Information
Insurance Name
None
AARP
Acordia Benefits Of Texas,Inc.
Aetna
Aetna Better Health
AFLAC
AIDS Services Of Austin
AISD Vision & Hearing Screening Program
Allegiance Benefit Plan Management, Inc.
Allied Benefit Systems
Allsup Inc
Amerigroup
Ameritas
Assurant Health
Assured Benefits Administrator
Austin Lion's Club
Avesis
Beech Street
Benefit Planners, Inc.
Block Vision
Blue Cross And Blue Shield
Blue Cross and Blue Shield of North Dakota
Care Improvement Plus
CBA
CHAMPVA
Cigna Health Care
Coast-to-Coast Discount Plan
Cole Managed Vision Care
CommUnityCare
Corporate Benefit Services of America
Davis Vision
Dell Laser Consultants
Department of Veterans Affairs
Emblem Health
envolve Benefit Options
Excellus Benefit Services
Eye LASIK Austin
EyeMed Vision Care
Eyetopia Vision Care
Fallon Health & Life Assurance Company
First Health
FiServ
Foundation for the Homeless
GEHA
General American
Great West Health Plans
Group Administrators, Ltd.
Group and Pension Administrators
Group Health Incorporated
Guardian
Harvard Pilgrim Health Care
HealthFirst Third Party Administrators
HealthPartners
HealthSmart
Heraeus Amersil Inc
HRA/HSA Account
HRHG Benefits Services, Inc.
Humana
Insurance Management Administrators
Johnson and Johnson
LifeRe Insurance Company
Loyal American Life Insurance Company
Lumenos
Medicaid - Block Vision
Medicaid - Opticare
Medicaid - Traditional
Medicare
Medicare Palmetto G.B.A.
Medicare Supplement
MEDIPLUS
Meritain Health
Metropolitan Life
Miscellaneous
MPE Employee Benefit Services Inc.
MultiPlan
Mutual Assurance Administrators
Mutual of Omaha
No Insurance
None
Nueva Vida Iglesia
OneHealthPlan
Opticare
PALMETTO GBA - RAILROAD MEDICARE
Pflugerville Lions Club
PHCS
Phoenix Group Services
Physicians Health Choice
Preferred Care
Prevent Blindness
Principal Life Insurance Company
Railroad Medicare
Red Cross
Reliance Standard Life Ins Co
Risk Management Services
RMSCO
RSL Specialty Products Administration
Rural Carrier Benefit Plan
Scott & White Health Plan
Spectera/Optum Health
State Farm
Superior Vision Services, Inc.
Texas Commission For The Blind
Texas Community Care
Texas Diabetic Eye Disease Program
Texas Disability Determination Services
Texas True Choice
The Epoch Group, L.C.
Thrivent Financial for Lutherans
TLC Laser Center
TML Intergov Emp Benefits Pool
Tower Life Insurance Company
TRICARE
UMR
Unicare
United Health Allies Discount Plan
United Health Care
United of Omaha
Vision Care Plan
Vision Service Plan
Vision USA
WellMed
Workmen's Comp
XX1Contacts.com
xxPrincipal Financial Group
Z Aetna
Z Blue Cross Of Idaho
Z Bluecross Blueshield - Oregon
Z DMI Document Retrieval, Inc.
Z Mann Berkley Caplan Laser Cntr
Z National Heritage Insurance Co
Z New Horizon's Vision Center
Z Omaha Health Care Service Cntr
Z PCA/Local Office
Z PCA/VSP
Z Prucare
Z VSP - Arizona
ZGeneral American
ZProfessional Vision Care
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
Street Address
City
State
Zip
Phone Number
Birthday
SSN
Employer/School
Tertiary
Insurance Information
Insurance Name
None
AARP
Acordia Benefits Of Texas,Inc.
Aetna
Aetna Better Health
AFLAC
AIDS Services Of Austin
AISD Vision & Hearing Screening Program
Allegiance Benefit Plan Management, Inc.
Allied Benefit Systems
Allsup Inc
Amerigroup
Ameritas
Assurant Health
Assured Benefits Administrator
Austin Lion's Club
Avesis
Beech Street
Benefit Planners, Inc.
Block Vision
Blue Cross And Blue Shield
Blue Cross and Blue Shield of North Dakota
Care Improvement Plus
CBA
CHAMPVA
Cigna Health Care
Coast-to-Coast Discount Plan
Cole Managed Vision Care
CommUnityCare
Corporate Benefit Services of America
Davis Vision
Dell Laser Consultants
Department of Veterans Affairs
Emblem Health
envolve Benefit Options
Excellus Benefit Services
Eye LASIK Austin
EyeMed Vision Care
Eyetopia Vision Care
Fallon Health & Life Assurance Company
First Health
FiServ
Foundation for the Homeless
GEHA
General American
Great West Health Plans
Group Administrators, Ltd.
Group and Pension Administrators
Group Health Incorporated
Guardian
Harvard Pilgrim Health Care
HealthFirst Third Party Administrators
HealthPartners
HealthSmart
Heraeus Amersil Inc
HRA/HSA Account
HRHG Benefits Services, Inc.
Humana
Insurance Management Administrators
Johnson and Johnson
LifeRe Insurance Company
Loyal American Life Insurance Company
Lumenos
Medicaid - Block Vision
Medicaid - Opticare
Medicaid - Traditional
Medicare
Medicare Palmetto G.B.A.
Medicare Supplement
MEDIPLUS
Meritain Health
Metropolitan Life
Miscellaneous
MPE Employee Benefit Services Inc.
MultiPlan
Mutual Assurance Administrators
Mutual of Omaha
No Insurance
None
Nueva Vida Iglesia
OneHealthPlan
Opticare
PALMETTO GBA - RAILROAD MEDICARE
Pflugerville Lions Club
PHCS
Phoenix Group Services
Physicians Health Choice
Preferred Care
Prevent Blindness
Principal Life Insurance Company
Railroad Medicare
Red Cross
Reliance Standard Life Ins Co
Risk Management Services
RMSCO
RSL Specialty Products Administration
Rural Carrier Benefit Plan
Scott & White Health Plan
Spectera/Optum Health
State Farm
Superior Vision Services, Inc.
Texas Commission For The Blind
Texas Community Care
Texas Diabetic Eye Disease Program
Texas Disability Determination Services
Texas True Choice
The Epoch Group, L.C.
Thrivent Financial for Lutherans
TLC Laser Center
TML Intergov Emp Benefits Pool
Tower Life Insurance Company
TRICARE
UMR
Unicare
United Health Allies Discount Plan
United Health Care
United of Omaha
Vision Care Plan
Vision Service Plan
Vision USA
WellMed
Workmen's Comp
XX1Contacts.com
xxPrincipal Financial Group
Z Aetna
Z Blue Cross Of Idaho
Z Bluecross Blueshield - Oregon
Z DMI Document Retrieval, Inc.
Z Mann Berkley Caplan Laser Cntr
Z National Heritage Insurance Co
Z New Horizon's Vision Center
Z Omaha Health Care Service Cntr
Z PCA/Local Office
Z PCA/VSP
Z Prucare
Z VSP - Arizona
ZGeneral American
ZProfessional Vision Care
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
Street Address
City
State
Zip
Phone Number
Birthday
SSN
Employer/School
Medical History
Chief Complaint
Reason for Visit
Blurred vision
Distance vision blurry
Near vision blurry
vision blurry distance and near
wants to be fitted for contacts
needs new glasses
needs more contacts
red eye
pain in eye
loss of vision
injury to eye
itching
burning
stinging
dry eyes
Diabetic eye exam
annual doctor directed diabetic eye exam
broken glasses
Lost RX
failed screening at school
failed screening at pediatrician's office
Physician directed eye exam
Complete eye exam to rule out problems
Other
Secondary Reasons
Review of Ocular System
Ocular History
None
Itching
Burning, Stinging
Red
Floaters
Flashes Of Light
Eye Injuries
Eye Surgery
Amblyopia
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Other
Eye Meds
None
Cromolyn NA 4%
Visine
Patanol
Xalatan
Travatan
rewetting drops
Elestat
Vigamox
Alphagan
Refresh
Theratears
Genteal
Pred Forte
Lotemax
Alrex
Systane
Blink
Other
Last Eye Exam
1 year
2 years
3 years
Other
Doctor
Hamilton
Thames
Simonek
Other
Primary Vision Correction
None
Glasses-Full Time
Glasses-Readers Only
Contacts - Soft
RGPs
PMMA
OTC readers
Other
Do you have back up specs?
No
Yes
Other
Do you want new glasses?
Yes
No
Other
Type of CLs worn in past
None
Disposable
Conventional
Colored
RGP
PMMA
Cobalt Study Lens
Soft
Other
Cleaner
None
PureMoist
Optifree
Clear Care
Boston
Renu
Biotrue
Aquify
Other
Disposal
daily
2 weeks
monthly
weekly
yearly
Other
Wear Time
>2 hours today
All day
Occ. Overnight
Extended
8 hours
10 hours
12 hours
Overnight
Other
Days per Week
Hours Worn Comfortably
Family Ocular History
Glaucoma
No
Parents
Sibling
Grandparent
Other
Cataracts
No
Parents
Siblings
Grandparent
Other
Macular Degen
No
Parents
Siblings
Grandparent
Other
Retinal Detach
No
Parents
Siblings
Grandparent
Other
Crossed / Lazy
No
Parents
Siblings
Grandparent
Other
Review of Systems
General
None
Negative
Other
Ear, Nose, Throat
None
Allergies
Sinus Problems
Chronic Cough
Dry Throat / Mouth
Hard of Hearing
Other
Cardiovascular
None
Vascular Disease
HBP
Heart Surgery
Other
Respiratory
None
Asthma
Bronchitis
Emphysema
COPD
Other
Genital, Kidney, Bladder
None
painful urination
frequent urination
impotence
yellow jaundice
Other
Muscles, Bones, Joints
None
joint pain
stiffness
swelling
cramps
arthritis
Other
Skin
None
pimples, warts
growths
rash
Other
Neurological
None
numbness, paralysis
headache
seizures
migraines
Other
Psychiatric
None
anxiety
depression
insomnia
Other
Endocrine
None
diabetes
hypothyroid
hyperthoyroid
Other
Blood/Lymph
None
bleeding
cholestrolemia
anemia
Other
Allergic/Immunologic
None
sneezing
swelling
redness
itching
hives
lupus
Other
Gastrointestinal
None
Diarrhea
Constipation
Ulcer
Acid Reflux
Other
Medical History
Primary Care Physician
Doesn't Remember
Doesn't Have One
Other
Last Visit
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
Other
Reason For Visit
Check up
Annual
Specific
Other
Vitamins
None
A
E
C
Zinc
Xanten
Lutein
Other
Over The Counter
None
Asprin
Acetomenophin
Ibuprofen
Other
Pregnant Or Nursing
No
Yes
Unsure
Other
Recent Tetanus Shot
Yes
No
Other
Injuries, Surgeries, Hospitalization
None
Other
Family Medical History
Please choose from the drop down medical issues that have occured within your family. If there are multiple, please type these in the extra text boxes provided. Thank you!
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Hypertension
Other
Social History
Occupation
Hobbies
None
Art
Baseball
Astronomy
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Other
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
Type
None
Cigaretts
Chewing Tobacco
Other
How Long
Alcohol
No
Yes
Occasionally
Socially
Other
Type
None
Beer
Wine
Hard Liquor
Other
How Long
Illegal Drugs
No
Yes
Other
Type
How Long
STDs
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
Other
Race
White
Black or African American
Asian
Patient Declined to Specify
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other Race
Other
Ethnicity
Not Hispanic or Latino
Hispanic or Latino
Other
Patient Declined to Specify
Other
Preferred Language
English
French
German
Spanish
Other
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