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
Misc/Guardian		Drivers License #

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Billing Information

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

Copy Address From Above
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 Medical

Insurance Information

Insurance Name:	None New Insurance New Insurance AETNA ALWAYSCARE BENEFITS INC. AMERICAN MARITIME OFFICERS MEDICAL PLAN ASSURANT HEALTH/ ASA AVESIS BCBS Medicare Advantage BCBS TX BLOCK VISION, INC, BMA CIGNA Community Care PPO Community Eye Care DAVIS VISION ENTRUST Envolve Vision Freedom Life Insurance Company of America GOLDEN RULE INSURANCE COMPANY Health and Human Services Commision HealthFirst HUMANA HEALTH PLAN MEDICAID TX MEDICARE TX Meritain Health MES NVA OPTICARE PRINCIPAL FINANCIAL GROUP Safeguard Health Plans Security Life Insurance SPECTERA CORPORATION SUPERIOR VISION SVS VISION Taylor Benefit Resource TEXAN PLUS Tricare UMR - Wasau/UHIS UNITED HEALTHCARE OF TEXAS - HOUSTON UNITED HEALTHCARE OVATIONS INS, SOLUTIONS Unknown Import VCP VSP WELLCARE HEALTH PLANS
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 Medical

Insurance Information

Insurance Name:	None New Insurance New Insurance AETNA ALWAYSCARE BENEFITS INC. AMERICAN MARITIME OFFICERS MEDICAL PLAN ASSURANT HEALTH/ ASA AVESIS BCBS Medicare Advantage BCBS TX BLOCK VISION, INC, BMA CIGNA Community Care PPO Community Eye Care DAVIS VISION ENTRUST Envolve Vision Freedom Life Insurance Company of America GOLDEN RULE INSURANCE COMPANY Health and Human Services Commision HealthFirst HUMANA HEALTH PLAN MEDICAID TX MEDICARE TX Meritain Health MES NVA OPTICARE PRINCIPAL FINANCIAL GROUP Safeguard Health Plans Security Life Insurance SPECTERA CORPORATION SUPERIOR VISION SVS VISION Taylor Benefit Resource TEXAN PLUS Tricare UMR - Wasau/UHIS UNITED HEALTHCARE OF TEXAS - HOUSTON UNITED HEALTHCARE OVATIONS INS, SOLUTIONS Unknown Import VCP VSP WELLCARE HEALTH PLANS
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:

Primary Vision

Insurance Information

Insurance Name:	None New Insurance New Insurance AETNA ALWAYSCARE BENEFITS INC. AMERICAN MARITIME OFFICERS MEDICAL PLAN ASSURANT HEALTH/ ASA AVESIS BCBS Medicare Advantage BCBS TX BLOCK VISION, INC, BMA CIGNA Community Care PPO Community Eye Care DAVIS VISION ENTRUST Envolve Vision Freedom Life Insurance Company of America GOLDEN RULE INSURANCE COMPANY Health and Human Services Commision HealthFirst HUMANA HEALTH PLAN MEDICAID TX MEDICARE TX Meritain Health MES NVA OPTICARE PRINCIPAL FINANCIAL GROUP Safeguard Health Plans Security Life Insurance SPECTERA CORPORATION SUPERIOR VISION SVS VISION Taylor Benefit Resource TEXAN PLUS Tricare UMR - Wasau/UHIS UNITED HEALTHCARE OF TEXAS - HOUSTON UNITED HEALTHCARE OVATIONS INS, SOLUTIONS Unknown Import VCP VSP WELLCARE HEALTH PLANS
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 Vision

Insurance Information

Insurance Name:	None New Insurance New Insurance AETNA ALWAYSCARE BENEFITS INC. AMERICAN MARITIME OFFICERS MEDICAL PLAN ASSURANT HEALTH/ ASA AVESIS BCBS Medicare Advantage BCBS TX BLOCK VISION, INC, BMA CIGNA Community Care PPO Community Eye Care DAVIS VISION ENTRUST Envolve Vision Freedom Life Insurance Company of America GOLDEN RULE INSURANCE COMPANY Health and Human Services Commision HealthFirst HUMANA HEALTH PLAN MEDICAID TX MEDICARE TX Meritain Health MES NVA OPTICARE PRINCIPAL FINANCIAL GROUP Safeguard Health Plans Security Life Insurance SPECTERA CORPORATION SUPERIOR VISION SVS VISION Taylor Benefit Resource TEXAN PLUS Tricare UMR - Wasau/UHIS UNITED HEALTHCARE OF TEXAS - HOUSTON UNITED HEALTHCARE OVATIONS INS, SOLUTIONS Unknown Import VCP VSP WELLCARE HEALTH PLANS
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

Personal and Social History

Nickname:	Age:	Race:	Gender:	Ethnicity:	Preferred Language:
		(Declined) American Indian Asian Black or African American Native Hawaiin White Other	Female Male Other	(Declined) Hispanic or latino Not Hispanic or latino Other	English Spanish Other
Received influenza Shot?	Smoking Status:	Last Eye Exam:	Pregnant or nursing?	Occupation:	Employer:
No Yes Other	Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked declined Other		No Yes unsure Other
Interested In CL?	Ever Worn CL?	Current CL type:	Hobbies	Spouse/Parent Name:	Primary Vision Correction:
	No Yes Other				None Eye glasses Soft Contact lenses Hard Contact Lenses Glasses & Contact lenses Other
Interested in Refractive Sx?	Computer use
No Yes Other	1-2 hrs/day 3-6 hrs/day >6 hrs/day None Other

Medical, Personal, and Family History

Eye History:

Last Eye Doctor:	EyeTrauma:	Eye Surgery:	Vision Loss:	Diplopia:	Flashes:
	No Yes Other	No Yes Other	No Yes Other	No Yes Other	No Yes Other
Floaters:	Water:	Burn:	Itch:	Glaucoma:	Cataracts:
No Yes Other	No Yes Other	No Yes Other	No Yes Other	No Yes Other	No Yes Other
Other:

Medications

Eye Meds:	Systemic Meds:	Allergies:
		NKDA Sulpha PCN Other

No Current Meds

NKDA

Medical History

Primary Care Physician:	Last Physical Exam:
Bing Ami Foster Unknown Doesn't have one Other
Do You Have a History of Any Issues/Conditions in The Following Categories?
Hypertension:	Diabetes:	Heart Disease:	Thyroid:	Lung Disease:	Arthritis:
No Yes Other		No Yes Other	No Yes Other	No Yes Other	No Yes Other
Auto Immune:	Skin:	Gastric:	Urogenital:	Cancer:	Psych:
No Yes Other	No Yes Other	No Yes Other	No Yes Other	No Yes Other	No Yes Other
Neuro:	Blood:	General Health:
No Yes Other	No Yes Other

Family Med History:	Family Eye History:	NOTES:

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