Online Patient Form

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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 Employment Status
Marital Status Employer / School Name
Misc/GuardianDrivers License #



Primary Insurance

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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Insurance

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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary Insurance

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:
Sex:
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 MellitusHGA1C:
Hypertension Well Controlled w/ Medications
Hypercholesterolemia Heart Problems
Arthritis Depression/Anxiety
Hepatitis ADD/ADHD
Hypothyroidism Gout
Hyperthyroidism AIDS/HIV
MigrainesOther:


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:



Submit Data/Policies

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


View Notice of Privacy Practices & HIPAA

Signature: Date:

Financial Policy

Signature: Date:

Contact Lens Evaluation Agreement

Signature: Date:

Dilation or Retinal Photography Consent

Signature: Date:

FDT - Frequency Doubling Technology

Signature: Date:

Sales Invoice Notice

Signature: Date:

Texas Optometry Board - Patient Info Page

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.