Online Patient Form

Click here to return to the the previous website.

After completing all the forms, please Submit your Data on the final tab. Thank you!

Demographics


TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
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
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Insurance

Primary Vision Insurance

InsuranceName:
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:
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?:
Are you allergic to any medications?:
Do you take over the counter medications?:

Do you have any of these conditions?:
Injuries, Surgeries, Hospitalizations?:
Are you currently pregnant or nursing?:
Does your family have a history of these conditions?:

Chief Complaint

Reason for Visit:
Secondary Reasons:

Last Eye Exam: By Doctor: Results:

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

Primary Vision Correction:
Do you have backup glasses?: Planning to get new glasses?:

Do you wear contacts? If yes, what brand?: How long do you wear them per day?:
What solution do you use?: How often do you change them out?:

Social History

Hobbies: STD's:

Tobacco Use: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drugs: Type: How Long:

Review of Systems

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

General:
Ear/Nose/Throat:
Cardiovascular:
Respiratory:
Genitourinary:
Musculoskeletal:
Skin:
Neurological:
Psychiatric
Endocrine:
Blood/Lymph:
Allergic/Immune:
Gastrointestinal:

Submit Data / Sign HIPAA and COVID


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