Patient Welcome Form

Thank You For Choosing Marsh Eye Center! We are here to improve your life with vision. Please complete this brief patient history form to help us better serve you and click "Submit" on the last tab when complete!


How Did You Hear About Us? (Select One)
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer/School Name

Preferred Language:

Ethnicity:   Race: 

Billing Information Is The Billing Address Different?

Home Phone:
Work Phone:

Medical History

Chief Vision Issues For This Visit

Secondary Vision Issues For This Visit:


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


Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:

Preferred Pharmacy: Location: Phone:

Primary Care Physician: Phone: Fax: Last Visit:

Reason For 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: Type: How Long:

Alcohol: Type: How Long:


Do you have a history of any of the following in your family? (Please select from the drop downs below.)


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:


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

Race: Ethnicity: Preferred Language:

Height Ft.: Inch: Weight Lbs:
Please go to the next tab

Dilation/Retinal Photo

The Optomap produces a comprehensive image of your retina without the side effects of dilation. Thus, we can better prevent or reduce vision loss in our patients with a simple, quick and patient-friendly new exam. Any eye exam should always include a careful look at the retina, which is located at the back of the eye, to screen for abnormalities or disease. The sensitive tissue that makes up the retina is susceptible to a variety of diseases that can ultimately lead to partial loss of vision or even complete blindness. Early detection of any retinal abnormality is crucial. Previously, this could only be done by dilating the pupils, a procedure that many patients found uncomfortable, inconvenient and time-consuming.

The Optomap, using a new technology � the Panoramic200� Retinal Imaging System, enables us to see more of your retina than observed during dilated exams without the discomfort and inconvenience associated with pupil dilation. As a result, you will not experience blurred vision or sensitivity to light following your eye exam. (Dilation results in thirty minutes of waiting and 3 or more hours of blurred vision). It is important to note however, that should any abnormalities be detected, or if we cannot obtain an acceptable image, dilation may be necessary.

The Optomap exam is simple: at the push of a button, we can generate a computer image of your retina for immediate review. Experience with this technology has already led to improved disease detection and has possibly prevented vision loss and blindness in several patients.

Please go to the "Contact Lenses" Tab. If you're not getting contacts, you can proceed to the "Signature & Submittal" tab.

Contact Lenses

If you're not getting contacts, you can move to the "Submit Data" tab.


The contact lens evaluation and fitting is a separate procedure from the standard comprehensive eye examination therefore it is charged differently. Patients that request a prescription for contact lenses will be responsible for payment of both the comprehensive examination AND the contact lens evaluation fitting. In order to get your contact lens prescription renewed, you must get a contact lens fitting every year after your previous prescription expires. The contact lens evaluation fitting includes:

     - Contact lens evaluation, which includes measurements of your cornea
     - Selection of contact lenses for best visual outcome
     - Solution starter kit (For new wearers only)
     - Diagnostic contact lenses, including proper care, insertion and removal training if necessary.
     - Appropriate lens changes if needed
     - Follow Up visits up to 3 months. (Extra charge after the 3 month period)
     - Contact lens prescription when the proper follow-ups are taken.

What if I decide to get contacts later after my standard comprehensive examination?

Patients, who get a comprehensive eye exam and would like to get a contact lens evaluation fitting at a later date, must do so within a 90-day period if they wish to be charged for only the contact lens evaluation difference. Any requests for contact lens evaluation fitting after the 90-day period will require that the patient go through another full standard eye exam along with the contact lens evaluation fitting for any changes in the overall prescription.

Please go to the "Signature & Submittal" Tab.

Signature and Submittal

Signature & Submittal Page - Please Read Carefully

*PAYMENT AGREEMENT (click to view)
I authorize and request my insurance company to pay directly to the eye doctor or
ophthalmic group insurance benefits otherwise payable to me. I understand that my
eye care insurance carrier may pay less than the actual bill for services. Therefore,
I agree to be responsible for payment of the balance of all services rendered on my behalf
or that of my dependents. I have the right to revoke this Authorization at any time by
providing the practice with a signed written request. Until such a request is received the
Authorization will be in effect for six years from the date of the most recent signed Authorization.
About Your Insurance (click to view)

You have the right to expect your personal health information to be protected as outlined
in the Notice of Privacy Practices. The terms of the notice may change. If you desire, a copy of
the new Notice one will be provided to you by requesting one in writing from this practice. You can
request to have your consent to use your Protected Health Information revoked at any time with a
signed written request to this practice.
By checking this box you agree that you have read and understand this form.

*OFFICE POLICIES (click to view)
By checking this box, you are providing a signature on file for Marsh Eye Center and acknowledge that you have read our office policies.

By clicking the submit button below, I acknowledge that the information that I have
inputted is correct and to the best of my knowledge. It will be updated to my medical
records at Marsh Eye Center. If I need a copy of my HIPAA rights and Marsh Eye Center office
policies, I will ask any of the staff members of Marsh Eye Center for a hard copy. If you
are a cash pay or private pay, please scroll to the bottom and submit.

After Completing All Forms Submit Data on Final Tab