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!

What is the reason for your visit today?
Whom may we thank for referring you?
Preferred Optometrist:

Patient Demographics


TitleFirstLastMISuffix
Nickname
Address:
City:
State:  ZipCode:     
Home Phone:
Work Phone:
Other Phone:
Cell Phone:
Preferred Contact Method:
Email
Birthdate
Sex Male Female
Misc/Guardian
Occupation:
Employer/School:

Billing Information Is The Billing Address the Same?
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!

Personal Health History

(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:

Diabetes:
Date of Diagnosis:
Date of last Tetanus Shot:
Pregnant Or Nursing:

Any history of STD's:

Other Health Problems:

Medications, Allergies, Other Medical History


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

Smoking Status
Alcohol:
Illegal Drugs:

In Case We Need to Refer You, Please Add Health Insurance Information.


Medical Insurance:
Kaiser MR #:
Primary Care Physician:

Personal Ocular History

Do you wear glasses?
Do you wear contact lenses?:
Type:

Daily hours of computer use:
Hobbies:      

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:

Corneal Molding?: Start Date:

Family Ocular History

(Click Here If Everything Is Normal)

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




Lifestyle Index


Your responses will help make sure your receive the best care possible:


How Often Do You Experience Any Of These Symptoms?

Headaches
Stiffness/Neck Pain/Shoulder Pain
Discomfort With Computer Use
Tired Eyes
Dry Eye Sensation
Light Sensitivity
Dizziness




Vision Is More Than Just 20/20


Effective vision includes both good eyesight and strong visual skills.


Please Check All That Apply:

Lazy Eye (Amblyopia)
Eye That Turn (Strabismus)
Short Attention Span
Possible Learning Disability
Irritated And Itchy Eyes
Reading And Writing Take A Long Time
Fall Asleep When Reading
Hard To Function At The End Of The Day
Head Turns Or Tilts
Sometimes I See Double
Frequently Trip, Run Into Things, Or Knock Things Over
Hard To Remember What I Read. I Have To Re-Read A Lot
Skip Or Repeat Words/Lines While Reading
Reverse Words Or Letters
Things Look Blurry When Looking Up From Work
Poor Penmanship; Cant Write On A Line
Hard To Align Numbers Or Columns




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:

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.

Submit Data