Online Patient Form

Demographics

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:
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	Single Married Divorced Domestic partner Legally Separated Widowed	Employer / School Name
Primary Doctor	No Doctor Assigned Dr. Nguyen, Thai-An	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
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:

Primary Vision Insurance

InsuranceName:	None Advantica Aetna Aetna Vision Discount Allianz Worldwide Allstate Always Care Starmount AmeriBen Avesis Blue Cross Blue Shield Care Improvement Plus Cigna Cigna Vision Davis Vision Deal Well Discount Plan Eyemed Discount Plan Eyemed Vision Care Group and Pensions Admin Health Plans, INC Humana ISO Medicare MultiPlan MyCompBenefits/Humana Vision NALC health Benefit Plan-Cigna National Vision Administrators New Insurance Opticare PHCS Principal Financial Group Superior Vision TML IEBP UMR United american insurance Company United Healthcare United of Omaha Life Insurance Co. Vision Benefits of America Vision Service Plan
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:

Primary Medical Insurance

InsuranceName:	None Advantica Aetna Aetna Vision Discount Allianz Worldwide Allstate Always Care Starmount AmeriBen Avesis Blue Cross Blue Shield Care Improvement Plus Cigna Cigna Vision Davis Vision Deal Well Discount Plan Eyemed Discount Plan Eyemed Vision Care Group and Pensions Admin Health Plans, INC Humana ISO Medicare MultiPlan MyCompBenefits/Humana Vision NALC health Benefit Plan-Cigna National Vision Administrators New Insurance Opticare PHCS Principal Financial Group Superior Vision TML IEBP UMR United american insurance Company United Healthcare United of Omaha Life Insurance Co. Vision Benefits of America Vision Service Plan
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

Primary Care Physician:

Last Visit:

Reason:

What are your current medications?:	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other
Are you allergic to any medications?:	NKDA Codeine Penicillin Sulfa Other
Do you take over the counter medications?:	None Asprin Acetomenophin Ibuprofen Other

Do you have any of these conditions?:	Good health Diabetes Hypertension Cardiovascular disease Arthritis Headaches Seizure Disorder Thyroid Disease Lung disease Asthma Stroke Kidney disease Cancer Diagnosed As HIV+ Inflammatory Bowel Disease HX Of Drug/Alcohol Abuse Other
Injuries, Surgeries, Hospitalizations?:
Are you currently pregnant or nursing?:	No Yes Unsure Pregnant Nursing Other

Does your family have a history of these conditions?:

None Adopted Diabetes Hypertension Cancer Cardiovascular Disease Kidney Disease Lupus Thyroid Arthritis Stroke Other

Chief Complaint

Reason for Visit:

blurrred vision distance vision blurry near vision blurry vision blurry distance and near wants to be fitted for contacts needs new glasses 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 failed screening at school failed screening at pediatrician's office Physician directed eye exam Complete eye exam to rule out problems needs more contacts Other

Secondary Reasons:

Last Eye Exam:

N/A 1 year 2 years 3 years 4 years 5+ years 1st Eye Exam Never Other

By Doctor:

Results:

Do you have any of these eye conditions?:

None Dry eye Itching Burning, Stinging Amblyopia Trauma Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders Age related macula degeneration Light sensitivity Other

Does your family have a history of these eye conditions?:

None Glaucoma Macular degeneration Cataract Blindness Amblyopia Strabismus Retinal disorder Other

Primary Vision Correction:

None Glasses Reading Glasses Soft Contacts Hard Contacts Glasses and Contact Lenses Other

Do you have backup glasses?:

Yes No

Planning to get new glasses?:

Yes No

Do you wear contacts? If yes, what brand?:

How long do you wear them per day?:

8 - 10 Hours All day Occ. Overnight Extended Other

What solution do you use?:

Optifree Biotrue Renu Boston Clear Care Other

How often do you change them out?:

2 weeks monthly daily weekly yearly Other

Social History

Hobbies:

N/A None Astronomy Art Baseball 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

STD's:

None Gonorrhea Syphilis Hepatitis HIV TB Other

Tobacco Use:	No Yes Other	Type:	None Cigarettes Chewing Tobacco Other	How Long:
Alcohol Use:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:

Review of Systems

Do you currently have any of the following symptoms? Check all that apply:

General:	None Fever Weight Loss Weight Gain Fatigue Other
Ear/Nose/Throat:	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other
Cardiovascular:	None High BP Heart Surgery Vascular Disease Other
Respiratory:	None Asthma Bronchitis Emphysema COPD Other
Genitourinary:	None Painful Urination Frequent Urination Kidney Stones Impotence Yellow Jaundice Other
Musculoskeletal:	None Joint Pains Stiffness Swelling Cramps Arthritis Other
Skin:	None Acne Growths Rashes Other
Neurological:	None Numbness/Paralysis Headaches Seizures Migraines Other
Psychiatric	None Anxiety Depression Insomnia Other
Endocrine:	None Diabetes Hypothyroid Hyperthyroid Other
Blood/Lymph:	None Bleeding Cholesterolemia Anemia Other
Allergic/Immune:	None Sneezing Seasonal Allergies Swelling Redness Itching Hives Lupus AIDS Other
Gastrointestinal:	None Diarrhea Constipation Ulcer Acid Reflux Other

Submit Data / Patient Signatures

HIPAA Patient Privacy Policy

FINANCIAL RESPONSIBILITY

I understand that all professional fees are due and payable at the time of service and are non-refundable. If a courtesy spectacle recheck is needed, it must be done within 3 months from your initial exam. Any contact lens follow-up will be covered by the contact lens fit/evaluation fee, but it must be done within 3 months of your initial exam to avoid any further charges. Therefore, it is important to keep all follow-up visits within the global period.

CONSENT FOR USE OF INSURANCE INFORMATION

I, the undersigned, certify that I (or my dependent) have insurance coverage with the plan(s) given to the staff and assign directly to Thai-An Nguyen, OD, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by the insurance. I understand that my vision and/or health insurance coverage is a contract between myself and my insurance company. Although Dr. Nguyen and the staff have made every effort to verify my benefits before my appointment, no guarantee can be made that the information received is accurate since incorrect information may be provided by my insurance company from time to time. I understand that it is ultimately my responsibility as the patient to understand my vision and/or health insurance coverage as well as handle any charges my plan does not cover.

ACKNOWLEGEMENT OF PRIVACY PRACTICES

I acknowledge that I have read and understand the Notice of Privacy Practices as implemented by EyeVenue. The notice of Privacy Practices provides a description of our treatment, payment activities, and healthcare operations and how my medical information will be used and disclosed. I am also aware that I may request a copy of the Privacy Practices. I also consent to the use and disclosure of my information to only carry out treatments, payment activities and submission of insurances.

Please identify anyone you would like to have access to your health records:

1. Name Relation To Patient Phone #:
2. Name Relation To Patient Phone#:  

By signing below, I give consent for use of insurance and acknowledge receipt of Notice of Privacy Practices:

Patient Name:

** Professional fees are non-refundable. Payment is expected at the time services are rendered, including non-covered portions of insurance. Insurance information must be given to us before the start of the exam.**

COVID-19 Pandemic Essential Eye Exam and Treatment Consent Form

Please read the following statements and click on the following statements to indicate your agreement. If you cannot positively affirm to all these questions, you will be asked to postpone or reschedule your visit to a later date.

I do not currently, nor have I had in the last two weeks, a fever, cough, sore throat, shortness of breath, loss of smell/taste or other cold symptoms.

To the best of my knowledge, I do not have, nor have I been in direct contact with someone who has a confirmed diagnosis of COVID-19 or a presumptive positive COVID-19 test result in the last 30 (thirty) days.

Neither I, nor anyone living in my immediate household, have traveled outside of the state of Texas in the last 30 days.

On March 16th, 2020, The Centers for Disease Control and Prevention (CDC) issued the following Public Health Reminder:

Healthcare facilities and clinicians should prioritize urgent and emergency visits and procedures now and for the coming several months. The following actions can preserve staff, personal protective equipment, and patient care supplies: ensure staff and patient safety; and expand available hospital capacity during the COVID-19 pandemic:

Delay all elective ambulatory provider visits

Reschedule elective and non-urgent admissions

Delay inpatient and outpatient elective surgical and procedural cases

Postpone routine eyecare visits

I have read the above stated Public Health Reminder and have answered the health questions above honestly and to the best of my knowledge. I understand that EyeVenue, its doctors and staff are taking precautions to limit any potential exposure I may have to the COVID-19 virus. I also understand that there is no definitive way to eliminate potential exposure by one hundred percent.

By signing this form below, I agree that I will not hold EyeVenue or any of its doctors or staff personally responsible should I, or someone I come in contact with, become positively or presumptively positive diagnosed with the COVID-19 virus. There are certain inherent risks associated with an eye exam during an epidemic and I assume full responsibility for personal illness that may result and further release and discharge EyeVenue and its doctors and staff for injury, loss or damage arising out of my visit. I understand that Covid-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.

Print Legal Name Date