Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
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
Primary Doctor Misc/Guardian
Primary Care Doctor
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision

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:

Medical

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:

Additional

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:

Medical History


Chief Vision Issues For This Visit

Secondary Vision Issues For This Visit:



COVID-19 Screening
You must be able to answer NO to all the COVID questions. If you cannot please call the office for further instruction.
Within the last 14 days have you experienced any COVID symptoms (fever, chills, cough, shortness of breath/difficulty breathing, muscle/body aches, sore throat, new loss of taste or smell, headache, diarrhea, nausea or vomiting, congestion or runny nose)
Have you traveled in the last 14 days?
Have you or a member of your household had close contact with or cared for someone diagnosed with COVID-19 in the last 14 days?
Has anyone in your household been asked or required to quarantine based on contact with a person who has a confirmed or presumptive positive COVID-19 test result or diagnosis, or have been asked to quarantine?
DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
 ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

PATIENT MEDICAL HISTORY

Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:

Primary Care Physician: Last Visit:

List any Vitamins you take:

Please list any over the Counter medications:

Please list your current Prescription Medications: No Current Medications

Please list all drug allergies: No Known Drug Allergies

Smoking Status:

Alcohol:




PATIENT OCULAR HISTORY

Please select if you have had any of the following:

Please select your current Eye Meds:

Last Eye Doctor: Last Eye Exam:  

Primary Vision Correction: 

Type of CLs worn in past:  Wear Time: Disposal:

FAMILY OCULAR HISTORY

Glaucoma: Crossed / Lazy: Retinal Detach: Macular Degeneration: Cataracts:




Policies

Insurance Acknowledgment

I acknowledge that the benefits quoted are not a guarantee of payment until your insurance has processed the claim. If I am not eligible for these benefits I am responsible for the balance. If Dr. Alsup is accepting my medical benefits I will be required to pay for the refraction at the time of the services since it is not a covered charge. I authorize my doctor to act as my agent in helping me obtain payment from my insurance companies; I authorize payment directly to my doctor.
I have read the above and consent to the use and disclosure of my health information for the purposes of treatment, payment, and health operations. I understand I am financially responsible for all charges incurred by myself and/or dependents. By signing this form, I acknowledge that I have reviewed the information and the practice's policy notice and agree to the practice's use and disclosure of my protected health information and I agree to allow this practice to communicate with me via text, email, postal, or telephone.

Signature: Date:

Notice of Privacy Practices

This notice of privacy practices ("notice") describes how we may use for disclose your health information and how you can get access to such information. Please read it carefully here.

Changes to This Notice:
We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility. Copies of this Notice are also available upon request at our reception area.

Office Policy/Fee Verification
All visits to this office are payable at the time of service.
Fees paid for an eye exam and contact lens exams/fittings are NON-REFUNDABLE.
Contact lens prescriptions may only be released after the initial follow up care (if necessary) is completed and are valid for one year. If you have problems with the contacts you must notify or return for follow up care within 30 DAYS or be subject to additional fees.
A prescription recheck will be performed free of charge within 30 DAYS of the date of the exam; if this time period has elapsed a new exam will be required.


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