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 #

Is the Billing Address Different?

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 Insurance

Insurance Information

Insurance Name:	None 0 No Ins 0 Out of Network AARP Aetna All Savers Allied Benefit System AlwaysCare Vision Plan American Continental American National Insurance Company APWU HP ASI/ABPA Assurant Health Avesis BCBS BCBS Advantage Administrators Ark (WalMart) BCBS Anthem BCBS Fed Employee Prog BCBS of TX Benefits in a Card Blue View (Eyemed) Boon-Chapman CareFirst CHAMPVA CHCS Services Inc Cigna CIGNA Healthy Rewards Disc Plan Coast to Coast Vision Plan Colonial Penn Life Insurance Company Community First Health Comp Benefits/ Humana Vision Concordian Health Plan Consolidate Health Plans CoreSource DARS Davis Vision Davis Vision Affinity Disc Plan Davis Vision/Blue Vision EBA&M Corporation Edgen Group, Inc - Gilsbar, Inc EGP European Benefits Administrators Eyemed Eyetopia FCE Benefits GEHA GHI Gilbar LLC GOLDEN RULE GPA GPA / Healthwatch Great Fidelity Insurance Great West-Cigna GWH - Cigna HCC Medical Insurance HealthComp HealthFirst TPA HealthSmart Benefit Solutions Humana Humana Gold Humana Vision / EYEMED IMA, PPO Plus Innovante under CIGNA-GWH PPO ITPE Health & Welfare Fund Laborer's Nat'l Health Medi-Share Medicare Provider Line MedPartners Administrative Services Meritain Metlife (VSP) MultiPlan/PHCS National Association of Letter Carriers Health Benefit Plan NIPPON LIFE INSURANCE COMPANY OF AMERICA NO MEDICAL Office of Refugee Resettlement Omaha Insurance Company OptiCare PIPA Point Comfort Underwriters, Inc Premera Blue Cross Blue Shield of Alaska Professional Benefit Administrators Providence Administrative Service R H Administrators, INC Spectera StudentResources Superior Vision Traditional Medicaid TransAmerica Premier Travelers Worker's Comp Tricare TX True Choice UAPP Local 142 Welfare Fund UMR United American Ins Company United Claim Solutions/IMS-WH United HealthCare United Healthcare Vision USAA Insurance VESTA Veteran's Voucher ViaCare VSP WebTPA Wellmed WPS-VACAA VAPCCC3
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

Insurance Information

Insurance Name:	None 0 No Ins 0 Out of Network AARP Aetna All Savers Allied Benefit System AlwaysCare Vision Plan American Continental American National Insurance Company APWU HP ASI/ABPA Assurant Health Avesis BCBS BCBS Advantage Administrators Ark (WalMart) BCBS Anthem BCBS Fed Employee Prog BCBS of TX Benefits in a Card Blue View (Eyemed) Boon-Chapman CareFirst CHAMPVA CHCS Services Inc Cigna CIGNA Healthy Rewards Disc Plan Coast to Coast Vision Plan Colonial Penn Life Insurance Company Community First Health Comp Benefits/ Humana Vision Concordian Health Plan Consolidate Health Plans CoreSource DARS Davis Vision Davis Vision Affinity Disc Plan Davis Vision/Blue Vision EBA&M Corporation Edgen Group, Inc - Gilsbar, Inc EGP European Benefits Administrators Eyemed Eyetopia FCE Benefits GEHA GHI Gilbar LLC GOLDEN RULE GPA GPA / Healthwatch Great Fidelity Insurance Great West-Cigna GWH - Cigna HCC Medical Insurance HealthComp HealthFirst TPA HealthSmart Benefit Solutions Humana Humana Gold Humana Vision / EYEMED IMA, PPO Plus Innovante under CIGNA-GWH PPO ITPE Health & Welfare Fund Laborer's Nat'l Health Medi-Share Medicare Provider Line MedPartners Administrative Services Meritain Metlife (VSP) MultiPlan/PHCS National Association of Letter Carriers Health Benefit Plan NIPPON LIFE INSURANCE COMPANY OF AMERICA NO MEDICAL Office of Refugee Resettlement Omaha Insurance Company OptiCare PIPA Point Comfort Underwriters, Inc Premera Blue Cross Blue Shield of Alaska Professional Benefit Administrators Providence Administrative Service R H Administrators, INC Spectera StudentResources Superior Vision Traditional Medicaid TransAmerica Premier Travelers Worker's Comp Tricare TX True Choice UAPP Local 142 Welfare Fund UMR United American Ins Company United Claim Solutions/IMS-WH United HealthCare United Healthcare Vision USAA Insurance VESTA Veteran's Voucher ViaCare VSP WebTPA Wellmed WPS-VACAA VAPCCC3
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

Insurance Information

Insurance Name:	None 0 No Ins 0 Out of Network AARP Aetna All Savers Allied Benefit System AlwaysCare Vision Plan American Continental American National Insurance Company APWU HP ASI/ABPA Assurant Health Avesis BCBS BCBS Advantage Administrators Ark (WalMart) BCBS Anthem BCBS Fed Employee Prog BCBS of TX Benefits in a Card Blue View (Eyemed) Boon-Chapman CareFirst CHAMPVA CHCS Services Inc Cigna CIGNA Healthy Rewards Disc Plan Coast to Coast Vision Plan Colonial Penn Life Insurance Company Community First Health Comp Benefits/ Humana Vision Concordian Health Plan Consolidate Health Plans CoreSource DARS Davis Vision Davis Vision Affinity Disc Plan Davis Vision/Blue Vision EBA&M Corporation Edgen Group, Inc - Gilsbar, Inc EGP European Benefits Administrators Eyemed Eyetopia FCE Benefits GEHA GHI Gilbar LLC GOLDEN RULE GPA GPA / Healthwatch Great Fidelity Insurance Great West-Cigna GWH - Cigna HCC Medical Insurance HealthComp HealthFirst TPA HealthSmart Benefit Solutions Humana Humana Gold Humana Vision / EYEMED IMA, PPO Plus Innovante under CIGNA-GWH PPO ITPE Health & Welfare Fund Laborer's Nat'l Health Medi-Share Medicare Provider Line MedPartners Administrative Services Meritain Metlife (VSP) MultiPlan/PHCS National Association of Letter Carriers Health Benefit Plan NIPPON LIFE INSURANCE COMPANY OF AMERICA NO MEDICAL Office of Refugee Resettlement Omaha Insurance Company OptiCare PIPA Point Comfort Underwriters, Inc Premera Blue Cross Blue Shield of Alaska Professional Benefit Administrators Providence Administrative Service R H Administrators, INC Spectera StudentResources Superior Vision Traditional Medicaid TransAmerica Premier Travelers Worker's Comp Tricare TX True Choice UAPP Local 142 Welfare Fund UMR United American Ins Company United Claim Solutions/IMS-WH United HealthCare United Healthcare Vision USAA Insurance VESTA Veteran's Voucher ViaCare VSP WebTPA Wellmed WPS-VACAA VAPCCC3
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

Referred By:

Referring Doctor:

Primary Vision Correction

None

Contacts

Single Vision

Progressive Lens

Bifocal

Over The Counter Readers

Interested in Contact Lenses?

Yes

No

Ever Worn Contact Lenses?

Yes

No

Sunglasses?

Yes

No

Interested in Laser Vision Correction?

Yes

No

Backup Glasses for Contacts?

Yes

No

Hobbies:

List All Smoking and Drinking Habits:

MEDICAL PERSONAL AND FAMILY HISTORY

Eye History:

None Cataract Surgery - Right Eye Left Eye Both Eyes

Eye Injury/Trauma:


Laser Eye Correction/Photorefractive Keratectomy - Right Eye Left Eye Both Eyes

Primary Care Physician:

Any Eye Drops?:

None

Restasis

Artificial Tears

Allergy Drops

Systemic Medications:

None	Birth Control Medications	Hypertension Medications	N SAIDs PRN Medications
Acne Medications	Cholesterol Medications	Hydrochlorothiazide Medications	Plaquenil Medications
ADHD Medications	Diabetes Mellitus Medications	Lisinopril Medications	Synthroid Medications
Allergy Medications	Glipizide Medications	Lipitor Medications	Aspirin Medications
Gout Medications	Metformin Medications

List any other Systemic Medications:

Medical History:

Healthy	Pregnant
Diabetes Mellitus	HGA1C:
Hypertension	Well Controlled w/ Medications
Hypercholesterolemia	Heart Problems
Arthritis	Depression/Anxiety
Hepatitis	ADD/ADHD
Hypothyroidism	Gout
Hyperthyroidism	AIDS/HIV
Migraines	Other:

Immediate Family Medical History:

None Known

Diabetes Mellitus

Hypertension

Immediate Family Eye History:

None Known	Macular Degeneration	Amblyopia
Stabismus	Retinitis Pigmentosa	Glaucoma

Other:

List All Allergies to Medications:

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View Notice of Privacy Practices & HIPAA

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Financial Policy

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Contact Lens Evaluation Agreement

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Dilation or Retinal Photography Consent

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FDT - Frequency Doubling Technology

Signature: Date:

Sales Invoice Notice

Signature: Date:

Texas Optometry Board - Patient Info Page

Signature: Date:

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