Online Patient Form
Click here to return to the previous website.
After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!
Patient Information
Title:
Select
Mr.
Mrs.
Ms.
Dr.
Rev.
First
Last
MI:
Suffix:
Nickname:
Address:
Apt/Suite #:
City:
State:
Select
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
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Contact Method:
Select
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
F
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Select
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer/School
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Yes
Title:
Select
Mr.
Mrs.
Ms.
Dr.
Rev.
First:
Last:
MI:
Suffix:
Address:
Apt/Suite #:
City:
State:
Select
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
Zip Code:
Home Phone:
Work Phone:
Vision Insurance
Insurance Name:
Select
None
Ambetter by Envolve
Avesis
Blue View Vision
CENV by Envolve
Davis Vision
EyeMed Vision Care (Not Advantage Network)
FIVP by Envolve
Humana VisionCare Plan
IdealCare by Sendero Health Plans
Spectera EyeCare Networks
Superior Vision Services, Inc.
Vision Service Plan
Other
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
Insurance Name:
Select
None
Aetna (Not QHP)
Ameritas Life Insurance Corp
Blue Cross Blue Shield (Not Blue Choice, Texas Chip or Texas Star)
Boon-Chapman Benefit Administrators
Chesterfield Resources Inc.
Cigna Health Care (Not NETWORK plans)
First Health Network
Golden Rule Insurance Company
Government Employees Health Association
Guardian
Health First TPA
HealthScope Benefits
HealthSmart Preferred Care
Medicaid (Traditional Medicaid Only; No Managed Care Plans)
Medicare
Meritain Health
Metlife
Principal
Scott & White (Not EPO plans or Medicaid RightCare)
Tricare (Need referral from Primary Care Doctor for medical visits)
TriWest Healthcare Alliance (need referral from Department of Veteran's Affairs)
Tufts Health Plan
UMR
United Healthcare (Not UHC Community Plan)
WellMed
Other
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!
Reason for Visit:
blurry vision distance
blurry vision distance and near
blurry vision distance,near and intermediate
blurry vision intermediate
blurry vision near
burning
Diabetic eye exam
doctor directed visit
dry eyes
failed screening at school
flashes of light
floaters
injury to eye
itching
loss of vision
needs more contacts
needs new glasses
night vision problems
No vision problems
pain in eye
red eye
stinging
wants to be fitted for contacts
Other
Primary Vision Correction:
None
Contacts--soft disposable
Contacts--soft monovison
Contacts--soft multifocal
Contacts--soft disposable with readers
Glasses full time
Glasses as needed
Glasses-Distance Only
Glasses-Readers Only
Glasses-FT Bifocal
Glasses-FT Trifocal
Glasses-Progressive Bifocal
RGPs
PMMA
Other
Primary Care Physician:
Fax #:
Letter:
Yes
Please list all medications you currently take:
Are you allergic to any medications?:
Eye Meds:
None
Alphagan
Alrex
Blink
Cromolyn NA 4%
Elestat
Genteal
Lotemax
Patanol
Pred Forte
Refresh
rewetting drops
Systaine
Theratears
Travatan
Vigamox
Visine
Xalatan
Other
Over The Counter Meds:
None
Acetomenophin
Aleve
Antihistamines
Aspirin
Ibuprofen
Omega 3s
Other
Vitamins:
None
A
B
B12
C
D
E
Lutein
Multivitamins
Ocuvite
Xanten
Zinc
Other
Patient History
Check yes or no for the following conditions. For any YES answers, check all that apply in the drop down menu to the right of each question.
Ear/Nose/Throat:
No
Yes
Select
Seasonal Allergies
Sinus Problems
Hearing Loss
Other
Endocrine:
No
Yes
Select
Diabetes Type 1 Insulin Dependent
Diabetes Type 2
Hypothyroid Disease
Hyperthyroid Disease
Other
Heart Disease:
No
Yes
Select
High Blood Pressure
High Cholesterol
Clotting Disorder
Vascular Disease
Heart Surgery
Anemia
Other
Allergies/Immune:
No
Yes
Select
Seasonal Allergies
Allergy Shots/Drops
Rheumatoid Arthritis
Lupus
HIV+
AIDS
Other
Headaches:
No
Yes
Select
Migraines
Wake Up with Headaches
Headaches Occur After Work/School
Pain in Temples (Side of Head)
Pain in Forehead
Sinus Headaches
Other
Musculoskeletal:
No
Yes
Select
Arthritis
Rheumatoid Arthritis
Joint Pain
Head Injury
Neck Injury
Myasthenia Gravis
Other
Neurological:
No
Yes
Select
ADD
ADHD
ALS
Fibromyalgia
Headaches
Migraines
Multiple Sclerosis
Seizures
Other
Respiratory:
No
Yes
Select
Asthma
Emphysema
COPD
Bronchitis
Other
Gastro/Urological:
No
Yes
Select
Acid Reflux
Crohn's Disease
Colitis
ITBS
Ulcers
Other
Cancer:
No
Yes
Select
Bladder
Bone
Brain
Breast
Cervical
Colon
Kidney
Liver
Lung
Melanoma
Skin
Stomach
Throat
Thyroid
Uterine
Other
Pregnant/Nursing:
No
Yes -
Select
Pregnant
Possibly Pregnant
Nursing
Other
Other:
Patient Eye History
Check yes or no for the following conditions. For any YES answers, check all that apply in the drop down menu to the right of each question.
Ambylopia:
No
Yes
Select
Right eye
Left Eye
Other
Cataracts:
No
Yes
Select
Congenital
Age Related
Caused by Trauma to Eye
Had Surgically Removed
Other
Dry Eyes:
No
Yes
Select
Mild
Moderate
Severe
Use Drops at Least Daily
Use Ointment at Night
Use Lid Scrubs
Other
Eye Injury:
No
Yes
Select
Right Eye
Left Eye
Caused Permanent Vision Loss
Other
Eye Surgery:
No
Yes
Select
Right Eye
Left Eye
Both Eyes
LASIK
Cataract Surgery
Retinal Surgery
Lid Surgery
Pterygium Removal
Corneal Transplant
Glaucoma Surgery
Other
Flashes of Light:
No
Yes
Select
Followed by Headache/Migraine
Lasts for About 15 Minutes
Squiggly Lines or Pulsating Light
Lightning Bolt Flash for no Apparent Reason
Other
Floaters in Vision:
No
Yes
Select
Recently Noticed
Noticed Long Time Ago/No New Changes
Rare
Sudden Increase in Number
Affecting Vision
Other
Glaucoma:
No
Yes
Select
Use Drops Daily
See Glaucoma Specialist Regularly
Other
Itchy Eyes:
No
Yes
Select
Seasonally Due to Allergies
Persistent Throughout Year
Eyes are Watery and Red Also
Have Prescription for Daily Drops
Use Over the Counter Drops Often
Use Over the Counter Drops Occasionally
Other
Keratoconus:
No
Yes
Select
Right eye
Left eye
Both eyes
Wear Rigid Gas Permeable Contact Lenses
Wear Soft Contact Lenses
Wear of Combination of Corrective Lenses
Have had Corneal Surgery
Other
Retinal Disorders:
No
Yes
Select
Retinal Detachment
Macular Degeneration
Diabetic Retinopathy
Other
Strabismus:
No
Yes
Select
Right Eye Turns In
Right Eye Turns Out
Left Eye Turns In
Left Turns Out
Vertical Strabismus
Corrected with Glasses
Corrected with Prism in Glasses
Corrected by Surgery
Other
Other:
No
Yes
Family Eye History
Check yes or no for the following conditions. For any YES answers, check all that apply in the drop down menu to the right of each question.
Cataracts:
No
Yes
Select
Mother
Father
Sibling
More Than One Sibling
Grandparent
More Than One Grandparent
Aunt(s)/Uncle(s)
Other
Glaucoma:
No
Yes
Select
Mother
Father
Sibling
More Than One Sibling
Grandparent
More Than One Grandparent
Aunt(s)/Uncle(s)
Other
Retinal Detachment:
No
Yes
Select
Mother
Father
Sibling
More Than One Sibling
Grandparent
More Than One Grandparent
Aunt(s)/Uncle(s)
Other
Macular Degeneration:
No
Yes
Select
Mother
Father
Sibling
More Than One Sibling
Grandparent
More Than One Grandparent
Aunt(s)/Uncle(s)
Other
Cross/Lazy Eye:
No
Yes
Select
Mother
Father
Sibling
More Than One Sibling
Grandparent
More Than One Grandparent
Aunt(s)/Uncle(s)
Other
Keratoconus:
No
Yes
Select
Mother
Father
Sibling
More Than One Sibling
Grandparent
More Than One Grandparent
Aunt(s)/Uncle(s)
Other
Social History
Occupation:
Engineer
Firefighter
IT
Nurse
Police officer
Salesman
Software engineer
Student
Teacher
Other
Hobbies:
Astronomy
Art
Baseball
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
None
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Other
Race:
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity:
Non Hispanic or Latino
Hispanic or Latino
Other
Preferred Language:
English
Spanish
French
German
Chinese
Vietnamese
Italian
Other
Other
Smoking Status:
Never Smoker
Current every day smoker
Current some day smoker
Former smoker
Smoker, current status unknown
Unknown if ever smoked
Other
If yes, Type:
None
Chewing Tobacco
Cigarettes
E Cigarettes
Marijuana
Other
How Long Smoked:
1 year or less
5 years or less
5 - 10 years
10 - 15 years
15 - 20 years
20+ years
Other
How Long Stopped:
1 year or less
5 years or less
5 - 10 years
10 - 15 years
15 - 20 years
20+ years
Other
Submit Form
**Click Here to View Our Notice of Privacy Practices**
I acknowledge that I have received and agree to the offices HIPAA Policies. If signing for a minor, I attest that I have legal authority to make medical decisions for the minor.
Okay To Upload Prescriptions To The Online Portal.