Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

All Fields Marked With * Are Considered Required Fields.

Patient Information


Title*First*LastMISuffixNicknamePronoun
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
*SSN Email
*Birthday Occupation
Birth Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address Different?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Primary Medical - PPO Plans Only

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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary 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:
Sex:
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!

Eye History

Reason for Visit:
Primary Reasons: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: Last Appointment Type By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Medical History

Medications: Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot: Recent Flu Immunization:


Do you have any of these medical conditions?:

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History



Does anyone in your family have any of these medical conditions?:

High Blood Pressure: Diabetes:
Thyroid Conditions: High Cholesterol:
Heart Conditions: Other:
Cancer:

Family Eye History

Does anyone in your family have any of these eye conditions?:

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Blindness:

Review of Systems

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

Social History

Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:
STD

Submit Form / Patient Signatures



ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

Notice to our patients - We are required to provide you our notice of privacy practices, which states how we may use and or disclosure health information. Please sign this form to acknowledge you were given the option to read through this notice.

*You may refuse to sign this acknowledgement *    * You may also request a copy*

I acknowledge that I was given the option to look over this offices notice of privacy practices.

Please print (patient's) Name:
Print your Name:
*Patient/Parent/ Legal Guardian Signature:
*Date:

HIPAA acknowledgement of the notice of privacy practices.
This one does not constitute legal advice and covers only federal, not State law

Cancellation / No Show Policy

Our office utilizes an automatic recall system to remind you of your appointments by text or email several times prior to your scheduled appointment with us.

1. Cancellation no show policy for the doctor appointment:

We understand that there are times when you must miss an appointment due to emergencies or obligations for work and family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting on our schedule. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for your visit, due to a seemingly "full" appointment book. If an appointment in not cancelled 24 hours in advance, you will be charged the $25 fee; it will be the patient's responsibility to pay as this will not be covered by your insurance. Failure to pay within 30 days of the scheduled appointment will result in collection fees in addition to the balance owed.

2. Scheduled appointments that are running late

We understand that delays can happen. However, we must try to keep the other patients and the doctor on time. If you are 10 minutes past our scheduled time we may have to reschedule the appointment if the schedule does not allow for the delay.

3. Account balances

We do require that the balances are paid in full at the time of services, and any previous account balances (self or family) are paid in full prior to receiving any further services by our practice. Failure to pay balances 30 days within the appointment date can result in being sent to collections. It is not a pleasant experience for our office or for you to deal with collections and we would appreciate your timely attention to balances that are owed.

Patient Printed Name:
*Patient/Parent/Guardian Signature:
*Date:

Insurance Information

Insurance is billed as a courtesy to you.

By signing this form below, it gives our office your authorization to release your personal information to the insurance company.

This office does not submit secondary insurance or out-of-network plans and is the patient's responsibility. The patient or legal guardian is responsible for all remaining balances not paid by your insurance company.

As stated by your insurance provider, authorization of your benefits does not provide a guarantee of payment and that final determination can only be made when the claim is processed.

Payment of outstanding balances are due within 30 days of balance notice. Medical visits are filed under medical insurance plans and specialist copays are due at every visit.

By signing below, I acknowledge and agree to the terms of this form in its entirety.

Patient Printed Name:
Responsible Party Signature:
Date:

Responsible Party Informations -

Please list the person who is financially responsible for the account. Please verify that we have your accurate information.

Mr. Mrs. Miss Ms. Parent of (child name):

First Name: Last Name:

Address:

City: State:

Zip Code:

Cell Phone: Alternate Phone:

*Date Of Birth: *Last Four of Social Security Number

Email Address:

Vision Insurance: VSP Eyemed Superior Vision Out Of Pocket

Medical Insurance Name:

ID#: Group #:

Policy Holder's Name: Policy Date Of Birth:

Policy Holder's last four of Social Security Number:

We require that patient fees are paid at the time services are rendered. Orders will not be processed until balances are paid in full. The undersigned will be responsible for any bills incurred in this office regardless of insurance. Accounts 30 days past due are subject to collection and legal fees in addition to the balances owed. There will be a service charge on all returned checks.

Please ensure that you are completely happy with your selections as all sales are final. Contact lens fees are separate from comprehensive exams and fees will apply. Our office allows 30 days to finish contact lens fits; after which refitting fees may apply. It is a patient’s responsibility to return for their appointment as indicated. For contact lens follow-ups, contacts must be worn at least 2 hours prior to you scheduled appointment.