Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	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

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Primary Doctor	No Doctor Assigned Dr. Nguyen, Duong	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

City	State	ZipCode
	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

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AETNA AETNA DISCOUNT AETNA EXAM ONLY AVESIS BLUE CROSS OF CALIF CLAIMS DEPT. CIGNA DIRECT DAVIS VISION EYEMED EYEMED DISCOUNT HUMANA MEDICARE ADVANTAGE MEDICARE CLAIMS DEPT. MES MES DISCOUNT ONECARE OPTUMHEALTH PRIVATE SAFEGUARD SAFEGUARD/HEALTH FAMILY SPECTERA UNITED HEALTH CARE Unknown Import VBA VSP VSP CHOICE VSP HEALTHY FAMILIES VSP REGIONAL VSP SCAN VSP SIGNATURE VSP STATE/REGIONAL VSP VALUE
Insurance Plan:
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:

Secondary

Insurance Information

Insurance Name:	None AETNA AETNA DISCOUNT AETNA EXAM ONLY AVESIS BLUE CROSS OF CALIF CLAIMS DEPT. CIGNA DIRECT DAVIS VISION EYEMED EYEMED DISCOUNT HUMANA MEDICARE ADVANTAGE MEDICARE CLAIMS DEPT. MES MES DISCOUNT ONECARE OPTUMHEALTH PRIVATE SAFEGUARD SAFEGUARD/HEALTH FAMILY SPECTERA UNITED HEALTH CARE Unknown Import VBA VSP VSP CHOICE VSP HEALTHY FAMILIES VSP REGIONAL VSP SCAN VSP SIGNATURE VSP STATE/REGIONAL VSP VALUE
Insurance Plan:
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:

Tertiary

Insurance Information

Insurance Name:	None AETNA AETNA DISCOUNT AETNA EXAM ONLY AVESIS BLUE CROSS OF CALIF CLAIMS DEPT. CIGNA DIRECT DAVIS VISION EYEMED EYEMED DISCOUNT HUMANA MEDICARE ADVANTAGE MEDICARE CLAIMS DEPT. MES MES DISCOUNT ONECARE OPTUMHEALTH PRIVATE SAFEGUARD SAFEGUARD/HEALTH FAMILY SPECTERA UNITED HEALTH CARE Unknown Import VBA VSP VSP CHOICE VSP HEALTHY FAMILIES VSP REGIONAL VSP SCAN VSP SIGNATURE VSP STATE/REGIONAL VSP VALUE
Insurance Plan:
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!

Chief Complaint

Reason for Visit:

Eye Exam, New Eye Exam, Est CL Exam, New CL Exam, Est Blurry dist Blurry reading Blurry computer Blurry dist & reading Update eyeglasses Update CL Failed school screening Failed pediatrician vision screening Eye strain Double vision Red eye Loss of vision Dry burning eye Itchy eye Eye pain Eye injury Diabetic eye exam Vision certification Other

Quality:	-- blurry vision flashes floaters loss of vision dry itchy pain light sensitive dizzy dull throbbing Other	Severity:	-- Mild Moderate Severe Other	Location:	-- Both Eyes Right Eye Left Eye Other
Duration:	-- Today 1 day 1 week 1 month 3 months 6 months 1 year Other	Timing:	-- Always Sometimes Morning Evening Night Other	Context:	-- indoor outdoor computer reading driving Other
Modifying:	-- Medication Eye drops Rest Other	Associated:	-- dizzy headache loss of vision blurred vision eye pain Other

Secondary Reasons:

Update spectacles Update contacts Blurry distant Blurry reading Blurry distant & reading Eye strain Double vision Dry, burning eyes Itchy eyes Diabetic eye exam Eye pain Eye injury Red eye Other

Quality:	-- no change worse better constant throbbing slightly worse a little better much better Vision is good Other	Severity:	-- Mild Moderate Severe Other	Location:	-- Both eyes Right eye Left eye Other
Duration:	-- ongoing 1 day 2 days 3 days 4 days 5 days 6 days 1 week 1 month 3 months 6 months 1 year Other	Timing:	-- Always Sometimes AM PM Other	Context:	-- computer outside reading driving tv school Other
Modifying:	-- Medication Glasses help Drops help Contacts Help Other	Associated:	-- dizzy headache loss of vision blurred vision eye pain Other

Review of Ocular History

Ocular History

Unremarkable Dry eye Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders Other

Eye Meds:

None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other

Doctor:

LCO Doesn't Remember Kaiser Harrison Cler & Cook Hartley Other

Last Eye Exam:

1 year 2 years 3 years Other

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA OTC readers Other

Family Ocular History

Glaucoma:	No Parents Sibling Grandparent Other	Macular Degen:	No Parents Siblings Grandparent Other
Cataracts:	No Parents Siblings Grandparent Other	Retinal Detach:	No Parents Siblings Grandparent Other
Crossed / Lazy:	No Parents Siblings Grandparent Other

Contact Lens Wearers Only

Type of Contact Lenses:

Unspec Dailies Total1 Dailies AquaComfort Clariti 1day MF Proclear 1day MF 1day AV Moist AV Oasys Air Optix Biofinity Freshlook Colors Duette HD Duette Prog Gas permeable Monovision Other

Wear Time:

12 hours Overnight 8 hours 10 hours Extended Other

Solutions:

Optifree Clear Care Biotrue Generic Peroxiclear Boston Other

Disposed:

daily 2 weeks weekly monthly quarterly yearly Other

Days/Week Worn:

all week 1-2 3-4 5-6 Other

Social History

Occupation:

Unspecified Accountant Administrator Artist Attorney Banker CEO CFO College Consultant Designer Domestic Engineer Executive Financial Firefighter Graduate Human resource Law enforcement Marketing Masseuse Medical doctor Nurse PhD Retired Realtor Sales Student Teacher Tourist Veterinarian Other

Hobbies:

None Art Baseball Boating Basketball Computers Cooking Crafts Dancing Diving Exercise Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Pottery Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Painting Woodworking Work out Other

Employer:

Smoking:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	Type:	None Cigarettes Chewing Tobacco Other	How Long:
Alcohol:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:

Illegal Drugs:

No Yes Other

Type:

How Long:

Any STDs?:

None Unsure Gonorrhea Syphilis Hepatitis HIV TB Other

Race:

Unspecified Caucasian Asian Hispanic Latino African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other Race Other

Ethnicity:

Unspecified European Hispanic or Latino Japanese Chinese Other Other

Preferred Language:

English French German Spanish Chinese Other

Review of Systems

Fever/Weight Loss:	No Yes Other
Ear, Nose, Throat:	None Allergies Sinus congestion Running nose Chronic Cough Dry mouth/ throat Hard of Hearing Other
Integumentary/Skin:	None Wart Growth Rash Other
Muscles, Bones, Joints:	None Arthritis Rheumatoid arthritis Joint pain Stiffness Swelling Cramps Other
Respiratory:	None Asthma Bronchitis Emphysema COPD Other
Cardiovascular:	None Diabetes Hypertension Heart disease Vascular Disease Other
Endocrine:	None Hypothyroid Hyperthoyroid Hormonal Other
Lymph/Hematologic:	None Anemia Uncontrolled bleeding Cholesterolemia Other
Immunologic:	None Hay fever Systemic lupus Rheumatoid arthritis Crohn's disease Other
Cancer/Immunosuppressed:	None Lung Breast Skin Brain Colon HIV positive Other
Gastrointestinal:	None Diarrhea Constipation Ulcer Acid Reflux Other
Genitourinary:	None painful urination frequent urination impotence Other
Neurological:	None Headache Migraines Seizures Numbness Tingling Paralysis Other
Psychiatric:	None Anxiety Depression Insomnia Obsessive compulsive ADHD Autism Other

Medical History

Pregnant Or Nursing:	No Yes 1st trimester 2nd trimester 3rd trimester Other
Primary Care Physician:	Unspecified Kaiser Caduceus LB Other	Last Visit:	1 yr 2 yrs 5 yrs 10 yrs 1 week 1 month 3 months 6 months Other
Reason For Last Visit:	Physical Other

Drug Allergies:

NKDA Penicillin Aspirin Sulfa Cephalexin Other

Over The Counter Meds:

None Asprin Acetomenophin Ibuprofen Other

Injuries, Surgeries, Hospitalization:

None Other

HIPAA Privacy Notice

NOTICE OF PRIVACY POLICY REGARDING YOUR MEDICAL INFORMATION

The privacy of your medical information is important to us. We understand that your medical information is personal and we will do everything we can to protect it. With every visit, we create a medical record of the care and services that you receive at our office. We will not use or disclose this record for any purposes not listed below without your specific written authorization:

FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose your medical information to doctors, nurses, technicians, or other people who take care of you. We may also share your medical information to other health providers to assist them in treating you.

FOR PAYMENTS: We may disclose your medical information to a third party for payment and reimbursement purposes.

FOR GOVERNMENT FUNCTIONS: Subject to certain requirements, we disclose your health information for national security and intelligence activities, for the Department of State, for correctional institutions and other law enforcement agencies.

FOR COURT ORDERS AND JUDICIAL PROCEEDINGS: We may disclose your medical information in response to a court order, subpoena, or other lawful requests under certain circumstances.

FOR PUBLIC HEALTH AGENCIES: As required by law, we may disclose your medical information to public health officials charged with preventing or controlling disease, injury, or disability including child abuse and neglect. We may also contact the Food and Drug Administration with your medical information regarding product defects and recalls.

FOR AGENCIES RESPONSIBLE FOR ABUSE, NEGLECT, OR DOMESTIC VIOLENCE: We may use and disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health and safety or the health and safety of others.

WORKERS COMPENSATION: We may disclose health information when necessary to comply with laws relating to workers compensation or other similar programs.

FOR HEALTH OVERSIGHT AGENCIES: We may disclose your medical information regarding audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.

FOR APPOINTMENT REMINDERS: We may use your medical information for purposes of reminding you of your appointments.

YOU HAVE THE RIGHT TO:

• Get copies of certain parts of your medical information. You must make your request in writing. There may be charges for photocopying and postage if you want them mailed to you.


• Receive a list of all the time(s) we have shared your medical information for purposes OTHER than stated above.


• Request that we place additional restrictions on our use or disclosure of your medical information. However, we are not required to agree to these additional restrictions.


• Request that we communicate with you about your medical information by different means or to different locations.


• Request that we change certain parts of your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you with a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.


• You have the right to receive a paper copy of this privacy policy.

QUESTIONS OR COMPLAINTS: If you think that we may have violated your privacy rights. You can submit a written statement or complaint to our Doctor or the Department of Health and Human Services. We will provide you with the address to file your complaint. We will not retaliate in any way if you choose to file a complaint. Thank you for your understanding and acknowledgement of our privacy policy regarding your medical information. Please let us know if you have any questions or concerns. Dr. Duong Nguyen, O.D. Laguna Coast Optometry (949) 715-2499

I have read and agree to this policy.

Signature:

Date:

Policies, Consent, and Submit Data

INSURANCE AND FINANCIAL RESPONSIBILITY AGREEMENT

I hereby authorize payment of vision insurance benefits to Laguna Coast Optometry and Duong Nguyen O.D. Inc. for professional services and optical products rendered. I authorize the release of any medical information necessary in order to process my insurance claims on my behalf. I understand that I am financially responsible for all services and products rendered at the time of service, whether or not covered by my insurance. If any co-pays and/or deductibles are required, I agree to pay them to Laguna Coast Optometry. Should there be any disputes regarding my insurance or vision benefits, I will settle them on my own with my insurance or employer.

I have read and agree to this policy.

Signature:

Date:

CONTACT LENS FITTING POLICY

1. Contact lenses, including non-prescription color & cosmetic lenses, are medical devices that require proper contact lens fitting, solution care, and replacement schedule.

2. Contact lens prescriptions are different than those of eyeglasses, and therefore would require a contact lens fitting.

3. Most contact lens fitting will include free diagnostic trials, except for custom contacts.

4. Proper contact lens care is patient's sole responsibility per doctor's instructions. Any deviation from proper contact lens care, including over-wear or change in lens solution, can result in eye irritation, infection, or other complications.

5. Contact lens trials must be worn on all follow-up visits. We cannot dispense lost, torn, or misplaced trials without a follow-up visit with the doctor. If patient continues to lose, tear, or misplace trials, s/he shall deem unfit for contact lens wear.

6. Contact lens fitting fees shall include an initial fitting plus 1 follow-up visit (at no additional charge). Any additional follow-ups will incur additional office visit fees. All contact lens fitting & follow-up charges constitute professional fees (non-refundable), whether patient decides to continue contact lens wear or not.

7. I understand and hereby consent to these contact lens policies - holding harmless Laguna Coast Optometry, Duong Nguyen O.D. Inc., or its affiliated optometrist(s) for any contact lens problem, infection, and/or permanent loss of vision due to non-compliance.

I have read and agree to this policy.

Signature:

Date:

INFORMED CONSENT

Retinal Photography:
Employs digitally enhanced camera to photograph the retina in order to better monitor for eye diseases like glaucoma and macular degeneration. It has no side effects similar to those of pupil dilation.

Dilation:
Serves the same purpose as retinal photography, except that light sensitivity and blurry reading will be experienced for about 4-6 hours afterward.

Eye pressure Test
I have been informed of the need for an eye pressure test to check for glaucoma. I understand that if I have glaucoma and an eye pressure test is not performed, the disease may go undetected resulting in possible loss of vision.


I understand that I will be responsible for any copay(s) associated with these procedures per my specific insurance plan. I approve for any or all procedures mentioned above as recommended by the Doctor - otherwise please check below to decline:

I decline the Retinal Photography.

I decline the Eye Dilation.

I decline the Eye Pressure Test.

I have read and agree to this policy.

Signature:

Date: