Online Patient Form

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After completing all the forms, please submit your data on the final tab. Thank you!

Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Cell Phone:
Email Preferred Contact Method:
SSN Employment Status Employed Full-Time Student
Part-Time Student
Birthday Occupation
Sex Male Female Employer / School Name
Marital Status Misc/Guardian
   How did you hear about us?
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Vision Insurance

Primary
Insurance Name:
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 Name:
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:
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Medical Insurance

Primary
Insurance Name:
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 Name:
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:
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Chief Complaint


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

Chief Complaint
Reason for Visit:
Secondary Complaints:
Notes:

Review of Ocular System
Ocular History/Surgery:
Eye Meds/Drops Used:
Last Eye Exam:

Family Ocular history
Glaucoma: Cataracts: Macular Degeneration:
Retinal Detachment: Crossed / Lazy:

Primary Vision Correction:
Do you have backup glasses?
Do you want new glasses?
Brand of contacts worn in past:
Contact Lens Solution Used:
Disposal Schedule:

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Medical History


Please choose from the menu options or select "OTHER" to type in multiple items or your own text.
Please review each drop down and indicate any current or previous history of the health conditions in each category.
GENERAL/OTHER:    No Health Issues, Fever, Weight Loss, Weight Gain, Fatigue
EAR, NOSE, THROAT:    Allergies, Sinus, Cough, Dry Mouth/Throat
CANCER:    Breast, Colon, Lung, Leukemia, Melanoma, Ovarian, Prostate, Skin
CARDIOVASCULAR:    High BP, Heart Surgery, Heart Disease, High Cholesterol
RESPIRATORY:    Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER:    Kidney Stones, Bladder Stones, Frequent Urination
MUSCLES, BONES, JOINTS:    Arthritis, Joint Pain
SKIN:    Eczema, Dermatitis, Acne, Rosacea, Shingles, Skin Cancer
NEUROLOGICAL:    Headaches, Migraines, Seizures, Stroke, Parkinson's, MS, Tremor
PSYCHIATRIC:    Depression, Anxiety, Insomnia, ADD, ADHD, Bipolar, Mood Disorder
ENDOCRINE:    Thyroid Disorder, Diabetes, Pituitary Tumor
BLOOD/LYMPH:    Anemia, Bleeding Problems
ALLERGIC/IMMUNOLOGIC:    Seasonal Allergies, RA, HIV, Lupus, Sjogren's
GASTROINTESTINAL:    Ulcer, Acid Reflux, IBS, Crohn's Disease
Patient Medical History
Primary Care Physcian: Phone:
Last Visit: Reason For Visit:

Current Medications:
No current medications
Drug Allergies:
No known drug allergies

Vitamins: Over the Counter Medications:

Pregnant Or Nursing:

Family Medical History:

Social History
Occupation:
Hobbies:
Smoking Status:
Alcohol:
Illegal Drugs:

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Policy Consent and Submit Data


PATIENT CONSENT FORM

The Department of Health and Human Services has established a "Privacy Rule" to help ensure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patient's consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take precautions to protect your privacy when it is appropriate and necessary. In order to provide health care that is in your best interest, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations.

We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients) and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but your refusal must be in writing under this law. We have the right to refuse to treat you should you choose to refuse to consent to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objections to this form, please ask to speak with our HIPAA compliance officer. You have the right to review our privacy notice, to request restrictions, and to revoke consent in writing after you have reviewed our privacy notice.

COMPLIANCE ASSURANCE NOTIFICATION FOR OUR PATIENTS

The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation, and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the "Privacy Rule." We strive to achieve the very highest standards of ethics and integrity in performing services for our patients.

It is our policy to properly determine appropriate uses of PHI in accordance with the government rules, laws, and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented a compliance program that we believe will help us prevent any inappropriate use of PHI.

Our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in any way compromises our policy of integrity. We welcome your input regarding any service problem so that we may remedy the situation promptly. Thank you for being one of our highly valued patients.

NOTICE TO PATIENTS REGARDING THE DESTRUCTION OF HEALTH CARE RECORDS

The 2009 Legislature set the following guidelines for record retention:
  • 1. Health care records for patients under age 23 may not be destroyed.
  • 2. Health care records of all other patients must be kept for a minimum period of five years.
  • 3. There is currently no federal law mandating a period for record retention. If one is subsequently passed, and if the period is greater than five years set by this law, the period will be extended to comply with federal law.
OFFICE POLICIES

If you are having problems with your contact lenses or glasses, you have 30 days for a follow up visit from the date of your exam. After 30 days there will be an additional charge.

THERE ARE NO REFUNDS ON SERVICES RENDERED. There are additional fees for optional services such as contact lens fittings, dilation, and retinal photos, which will be thoroughly explained at the time of your exam.

NO REFUNDS OR EXCHANGES will be given on contact lenses once ordered. For soft contact lens wearers, a trial pair will be provided during the exam to make sure the fit and vision are good prior to ordering.

NO REFUNDS will be given on RGP or hybrid contact lenses, as they are specialty made-to-order lenses.

IF YOU ARE USING VISION OR MEDICAL INSURANCE, BY SIGNING BELOW YOU ARE AUTHORIZING US TO BILL THEM, AND UNDERSTAND THAT YOU WILL BE RESPONSIBLE FOR ANY PORTION OF THE BALANCE NOT PAID BY YOUR INSURANCE (INCLUDING COLLECTION FEES). QUOTED BENEFITS ARE NOT A GUARANTEE OF PAYMENT.

There is a $25 cancellation fee if you are unable to make your appointment without 24 hours notice.

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

Checked:       Patient Signature:       Date: