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
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
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
Zip Code:
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
Guardian
Billing Information
Is The Billing Address the Same?
Yes
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
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
Zip Code:
Home Phone:
Work Phone:
Insurance
Insurance Name:
None
0 No Ins
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
CoreSource
DARS
Davis Vision
Davis Vision Affinity Disc Plan
Davis Vision/Blue Vision w/ BCBS
EBA&M Corporation
Edgen Group, Inc - Gilsbar, Inc
EGP
European Benefits Administrators
Eyemed
Eyetopia
FCE Benefits
GEHA
GHI
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
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
PreferredOne Community Health Plan
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
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 Name:
None
0 No Ins
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
CoreSource
DARS
Davis Vision
Davis Vision Affinity Disc Plan
Davis Vision/Blue Vision w/ BCBS
EBA&M Corporation
Edgen Group, Inc - Gilsbar, Inc
EGP
European Benefits Administrators
Eyemed
Eyetopia
FCE Benefits
GEHA
GHI
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
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
PreferredOne Community Health Plan
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
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
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Referred By:
Insurance
Friend/Family
Website/Internet
Yellow Pages
Walk-by/Drive-by
Other
Referring Doctor:
Primary Vision Correction:
None
Contacts
Single Vision Lenses
Progressive Lenses
Bifocals
Over The Counter Readers
Interested in Contact Lenses?:
Yes
No
Ever Worn Contact Lenses?:
Yes
No
Do you use Sunglasses?:
Yes
No
Interested in Laser Vision Correction?:
Yes
No
Have Backup Glasses for Contacts?:
Yes
No
Please list any hobbies:
Please list any eye conditions, injuries, or surgeries:
Eye Medications:
Acular
Artificial Tears
Bacitracin Ointment
Betoptic-S .25%
Betoptic .5%
Betagan
Erythromycin
FML
FML Forte
Gentamicin
Neosporin
Ocupress
Pilo Gel
Propine
Polytrim
Pred Mild
Pred Forte
Pataday
Patanol
Restasis
Systane
Timoptic .25%
Timoptic .5%
Tobradex
Voltaren
Xalatan
Other
Artificial Tears
Restasis
Allergy drops
Last Eye Doctor:
Pearl Dr.
Lens Crafter's Dr.
Eyemasters
Target Dr.
Wal-Mart Dr.
Today's Vision
Other
Primary Care Physician:
Systemic Medications:
None
Acne
ADHD
Allergy
Aspirin
Birth Control
Cholesterol
DM
Glipizide
Gout
HTN
Hydrochlorothiazide
Lisinopril
Metformin
NSAIDs PRN
Plaquenil
Synthroid
Other Medications:
Are you Allergic to Medications?:
Codeine
Cyclosporins
Erythromycin
Iodine
Pollen
PCN
Sulfa
Tetanus
Other
No Known Drug Allergies
Medical History:
Healthy
Diabetes Mellitus
Date Diagnosed:
A1c:
Hypertension
Date Diagnosed:
Well controlled with meds
Hypercholesterolemia
Arthritis
Hepatitis
Hypothyroidism
Hyperthyroidism
AIDS / HIV
Migraines
Gout
ADD / ADHD
Depression / Anxiety
Other:
Immediate Family History:
No medical history known
No eye history known
Diabetes
High Blood Pressure
Glaucoma
Macular Degeneration
Strabismus
Retinitis Pigmentosa
Amblyopia
Other:
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