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
Misc/Guardian

Is the Billing Address Different?

Billing Information

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

Copy Address From Above
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:

Primary Insurance

Insurance Information

Insurance Name:	None Advantica Cigna Vision Davis NVA Solstice 10,20,50 Superior Vision UHC/Spectera VSP
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:

Secondary Insurance

Insurance Information

Insurance Name:	None Advantica Cigna Vision Davis NVA Solstice 10,20,50 Superior Vision UHC/Spectera VSP
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:

Tertiary Insurance

Insurance Information

Insurance Name:	None Advantica Cigna Vision Davis NVA Solstice 10,20,50 Superior Vision UHC/Spectera VSP
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 History

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

What is your main reason for visit?:

no complaint blurry vision broken glasses burning discharge double vision dryness failed DMV failed vision screening flashes floaters headaches injury to eye itching laser vision consultation light sensitivity loss of vision lost glasses pain redness referred by MD routine exam stinging strain tearing want new eyeglasses wants contact lenses Other

Do you wear glasses?:	Yes	No
If yes, do you wear them for:	Distance	Near	Both
Do you wear Contacts?:	Yes	No

Date of Last Eye Exam:
Date of Last Medical Exam:
Primary Care Physician:

Do you have any allergies to medication?:

Yes

No

If yes, please list:

Do you have seasonal allergies?:	Yes	No
Are you taking medications?:	Yes	No

List Medications:

List Eye Medications:

Do you have:

None

High Blood Pressure

Diabetes

High Cholesterol

Thyroid Disease

Rheumatoid Arthritis

Sexually Transmitted Disease

Heart Disease

HIV/AIDS

Cancer

Other

Have you ever had:

None

Strabismus (eye turn)

Cataracts

Eye injury

Amblyopia (lazy eye)

Glaucoma

Diabetic Retinopathy

Macular Degeneration

Dry Eyes

Retinal Disease

Cataract Surgery

Lasik/PRK

Retinal Detachment

Strabismus Surgery

Other

Does anyone in your family have:

Condition	Mother	Father	Grandmother	Grandfather	Siblings
Cancer
Diabetes
Cholesterol
Hypertension
Heart Disease
Thyroid
Blindness
Glaucoma
AMD
Amblyopia
Strabismus
Eye Cancer

Other

Are you pregnant?:	Yes	No
Do you see flashes of light in your eyes?:	Yes	No
Do you see floating objects in your eyes?:	Yes	No
Do you have frequent headaches?:	Yes	No
Do you smoke?:	Yes	No
Do you drink alcohol?:	Yes	No
Are you nursing?:	Yes	No
Do you have temporary blackouts of your vision?:	Yes	No
Former smoker?:	Yes	No

Occupation:

Number of hours spent on computer:

Dry Eye Questionnaire

1. Questions about EYE DISCOMFORT:

a. During a typical day in the past month, how often did your eyes feel discomfort?

0-Never 1-Rarely 2-Sometimes 3-Frequently 4-Constantly

b. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?

0-Never have it 1-Not at all intense 2 3 4 5-Very intense

2. Question about EYE DRYNESS:

a. During a typical day in the past month, how often did your eyes feel dry?

0-Never 1-Rarely 2-Sometimes 3-Frequently 4-Constantly

b. When your eyes felt dry, how intense was this feeling of dryness at the end of the day within two hours of going to bed?

0-Never have it 1-Not at all intense 2 3 4 5-Very intense

3. Question about WATERY EYES:

During a typical day, in the past month, how often did your eyes look or feel excessively watery?

0-Never 1-Rarely 2-Sometimes 3-Frequently 4-Constantly

Submit Data, Policies, Consents

CONSENTS & INFORMATION

Click here for CONTACT LENS CONSENT AND CONTACT LENS REGIMEN FORM

I fully understand the risks and benefits of wearing contact lenses. I agree to return for my follow-up visit whose main purpose is to ensure the safety of my eyes. By signing this consent I agree to adhere to the contact lens instructions as stated above.

Patient Signature: Date:



Click here for CONSENTS & INFORMATION

MINORS:

I give permission for my child to have any diagnostic drops or contact lens service for an eye exam or contact lens fitting


DIALATION:

I, , understand the side effects and benefits of dilation and I AGREE to having my eyes
dilated today. I hereby authorize CGEFL associates to administer dilating eye drops.

I, , that I am opting against what is recommended for my comprehensive ocular health by the optometrist.
eyes dilated today.

OPTOMAP (Retinal Photo):

Yes, I will have an OPTOMAP (retinal photo) taken today for a co-pay of $34.00

I understand that I am opting against what is recommended for my ocular health by the optometrist.


I acknowledge that I have read this form, I understand its content, and do not have any questions. I am the patient or the person duly authorized
either by the patient or otherwise, sign this agreement, consent to, and accept its terms. I am responsible for the payment and/or co-payment that
is due at the time of service, and I have been given the option to for a copy of the CG Eyecare of Florida HIPPA Policy.


Patient (or person authorized to sign for patient) Date