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!

Patient Information


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

Billing Information

Is The Billing Address the Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
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!

Eye History

Primary Reasons: Secondary Reasons:

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

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

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Replacement: Sleep Frequency:
Wear Time: Hours/Day: Days/Week: Hour(s) Comfortably

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:


Review of Systems

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

Family Medical History



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

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

Diabetes:
Year Diagnosed: A1C:

Social History

Hobbies:

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

Race: Ethnicity: Preferred Language:
STD


Signature / Submit





Please select one of the following options:
I agree to Retinal & Visual Field Screening ($49)
I agree to Retinal Screening only ($39)
I agree to Visual Field Screening only ($25)
I do not want these procedures performed

Dilated Fundus Examination

Pupil dilation involves drops to dilate the eyes. This allows your doctor to examine the entire retina for diseases including tumors, hemorrhages, or retinal detachments. The drops take 20 minutes to work, and effects (light sensitivity, blurry vision) will be felt for about 4 hours.

Please select one of the following options:
I agree to dilation with no additional charge
I do not want to be dilated.

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Acknowledgment of Notice of Privacy Practices:

View HIPAA Patient Privacy Policy Form The law requires that Lewisville Eye Care makes every effort to inform you of your rights related to your personal health information. By signing below, I acknowledge that I was given the opportunity to read, have read or had explained to me Lewisville Eye Care Notice of Privacy Practice prior to any services offered.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

Signature: Date:

If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor.

Signature / Relationship To Patient: Date:

Financial Responsibility Policy:

We accept both vision and medical insurance which are very different in terms of the services they cover.

Vision insurance (e.g. VSP, Spectera) is a wellness benefit designed to reduce the cost of routine annual eye exams and prescription glasses and contact lenses.

Medical insurance (e.g. BCBS, Aetna, Medicare) is designed to help cover the cost of a medical problem, including one that affects your eyes. Examples include dry or itchy eyes, red eyes, eye pain, floaters, headaches and diabetes. Some medical insurance plans ALSO cover routine eye exams for patients who need a prescription for glasses or contact lenses and are otherwise healthy.

There is often no way to know prior to the exam, which type of insurance will be appropriate with which to file your claim, as this is based on the reason for your visit and the results of your exam. Insurance carriers set these rules and our office is required to follow them. We offer direct billing and in the event we are out of network with your insurance plan, we provide an itemized receipt so you may file with your carrier for reimbursement. Coverage will be verified before your exam, however, we are not responsible for discrepancies once the claim is filed. If you have any questions, please let us know before your appointment.

By signing below, I acknowledge that I have read this information and understand completely.

View Financial Responsibility Policy Form

Signature: Date:

Contact Lens Exam Agreement: (Please only sign if you are scheduled or thinking of having a contact lens eye exam)

View Contact Lens Agreement

I have read the contact lens patient care agreement and fitting fee. I understand the fitting procedure and that full payment is expected at the time a contact lens fitting is performed.

Signature: Date: ** By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I
        accept has the same validity and meaning as my handwritten signature.


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