Palmer Eye Associates/ Palmer Optical Online Patient Form


After completing all the forms, please submit your data via our secure server on the final tab. All fields are required so that we may obtain any need authorizations or other benefit information prior to your visit. Thank you!

Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
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
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information For all VBA members: Your ID number is the last four digits of the primary member's Social Security number. For all VSP members: Your ID number for most VSP plans is the last four digits of the primary member's Social Security number. Some VSP plans use the primary member's employee identification number as the member ID, so we ask that you provide both if applicable. For all MetLife Vision members: Your ID number is the last four digits of the primary member's Social Security number.
Insurance Name:
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:
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

CONSTITUTIONAL: Fatigue, Weight loss/gain, fever, chills, night sweats
OCULAR: Sudden Blurred vision, Dischage, dryness, Flashes/floaters , Loss of vision, pain
EAR, NOSE, THROAT: Runny Nose, Ear aches, Hearing changes, Vertigo, Sore throat
CARDIOVASCULAR: Chest pain, Palpitations, Swelling of feet, Pain with walking
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GASTROINTESTINAL: Abdominal pain, Difficulty swallowing, Change in bowel habits
MUSCULAR/SKELETAL: Joint pain/stiffness, swelling, reness/warmth, cramps
INTEGUMENTARY: Rash, Hair loss, Itching, Pigmented lesions
NEUROLOGICAL: Muscle weakness, Memory loss, Numbness, Tingling
PSYCHIATRIC: Anxiety, Depression, Hallucinations, Nervousness
ENDOCRINE: Heat/Cold intolerance, Excessive hunger, Excessive Thirst, Excessive urination
ALLERGIC / IMMUNOLOGIC: Swollen Lymph Nodes, Itching/Hives, Hay Fever, Sneezing
OTHER SYMPTOMS:

Submit Data