Online Patient Form - Edit If Needed

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After completing all applicable sections, please scroll down to the bottom and click "submit" to submit your data. Thank you!

Patient 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
Whom may we thank for referring you?

Billing Information Is The Billing Address the Different? If so Please Provide Billing Address Below
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical History


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Review of Systems

(Click Here If Everything Is Normal)

General: Skin:
Ear/Nose/Throat: Neurological:
Cardiovascular: Psychiatric:
Respiratory: Endocrine:
Genital/Kidney/Bladder: Blood/Lymph:
Muscles/Bones/Joints: Gastrointestinal:
Allergic/Immunologic: Other:

Medications, Allergies, Other Medical History

What is the reason for your visit today?

Primary Care Physician: Diabetes: Date of Diagnosis:
Medical Insurance: Kaiser MR #:
Date of last Tetanus Shot: Pregnant Or Nursing:

Other Health Problems:

Medications:  Allergies to Medications:
  
Vitamins:  Over the Counter Medications:
  

Family Ocular History

(Click Here If Everything Is Normal)

Glaucoma: Retinal Detachment:    Unknown family history
Macular Degeneration: Other Eye Condition:

Personal Ocular History

Do you have a history of: (Click Here If Everything Is Normal)

Eye Surgeries? If yes, Date:
Eye Injuries? If yes, Date:

Eye Turn: Lazy Eye: Patching: Vision Therapy:
Dry Eyes: Glaucoma: Cataracts: Concussions:

Do you wear glasses? Do you wear contact lenses?: Type:
Corneal Molding?:      Start Date:

Social History

Occupation: Employer/School: Daily hours of computer use:
Hobbies:      

Smoking Status Type: How Long:
Alcohol: Type: How Long:
Illegal Drugs: Type: How Long:

Any history of STD's:



VISION SKILLS CHECKLIST

Does reading or computer work take a more than a normal amount of time and effort?
Yes No

Is there a desire to see improvement in reading, studying or academics?
Yes No

Would improvement in coordination or in a particular sport be desirable?
Yes No

Please check all below that apply:

PHYSICAL / BEHAVIORAL
Squints and/or rubs eyes often
Burning, itching, or watery eyes
Tilts head or covers one eye while doing school work
Frequent after school/work headaches
Car or motion sickness
Dizziness or nausea during homework or other close work
Holds books very close or leans close to computer or TV
Complains of double vision
Not an accurate judge of distance
Poor hand-eye coordination
Poor or inconsistent performance in sports
Forgetful, poor memory
Clumsy, accident prone, knocks things over
First response is "I can't" before trying
Behavior problems, class clown
ADD/ADHD has been suggested
SCHOOL / ACADEMIC
Performance in school does not match capabilities
Takes hours to do 20 min. of homework
Difficulty completing assignments on time
Difficulty copying from the chalkboard
Avoids reading and other close work
Trouble keeping attention on reading
Words appear to run together when reading
Skips or repeats words/lines while reading
Needs frequent breaks during homework
Must re-read to comprehend
Writes up or down hill
Falls asleep when reading
Misaligns digits or columns of numbers
Does better with number problems than word problems
Reverses words or letters
School/work gets harder towards the end of the day



Contact Lens Policy


Please click on the blue links below, for the contact lens fitting fees. Read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

View Contact Lens Policy

Print Patient Name: Date:
Sign:


HIPAA Form


HIPAA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT INFORMATION BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

Date:

***By typing your name you agree that it represents your official signature***

Please print name of Patient: Patient's Signature (or legal representative):

Legal Representative/Guardian Name: Relationship of Legal Representative/Guardian:

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes step parents, grandparents, and any care takers who can have access to this patient's records):

Name: Relationship:

Name: Relationship:

I AUTHORIZE THIS OFFICE TO CONTACT ME VIA CELL, HOME OR WORK PHONE, EMAIL MESSAGE OR U.S. MAIL TO RELAY TREATMENT INFORMATION, BILLING INFORMATION, OR INFORMATION ABOUT MY HEALTH, AND TO NOTIFY ME ABOUT MY GLASSES AND/OR CONTACTS ORDER, SPECIAL SERVICES/EVENTS, NEW HEALTH INFO, AND YEARLY EXAM REMINDERS.

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. If we receive any remuneration, we, under current HIPAA Omnibus Rule, will provide you with this information and obtain your consent first.

After reviewing all of the information above, please press the "submit data" button to send in your forms.

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