Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Miss Dr. Rev. Fr.

Address:
City:		State/ZipCode	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		Age:
Occupation		Employer / School Name
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	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Miss Dr. Rev. Fr.

Address

City	State	ZipCode
	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 Information

Insurance Name:	None No Name Department of Rehabilitation Eyemed Vision Care Medical Eye Services VSP
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 Information

Insurance Name:	None No Name Department of Rehabilitation Eyemed Vision Care Medical Eye Services VSP
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:

Vision Plan

Insurance Information

Insurance Name:	None No Name Department of Rehabilitation Eyemed Vision Care Medical Eye Services VSP
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

Chief Complaint

Location

Right Eye Left Eye Both Eyes forehead back of the head left side of head right side of head right temple left temple neck distance intermediate near lower lid Right Eye lower lid Left Eye upper lid Right Eye uppr lid Left Eye Other

Quality

Severity

one on a scale of one to ten two on scale of one to ten three on a scale of one to ten four on a scale on one to ten five on a scale on one to ten six on a scal of one to ten seven on a scale one of ten eight on a scale of one to ten nine on a scale of one to ten ten on scale of one to ten Other

Duration

one hour one day one week one month one year a few hours Other

Timing

constant frequently in the evening intermittent rarely upon awakening varies Other

Context

Modifying Factors

worsens with improves with improves with glasses improves with contact lenses Other

Assoc. Signs/Symp

itching watering pus mucous redness tenderness dull pain stabbing pain blurred vision haloes around lights glare Other

Comments

Are you new to our practice?:

Yes No

If No, Last Visit:

Last Eye Exam:

Last Physical Exam:

Current Eye Symptoms

My eye history is negative for all of the following:

Blurred Vision	Night Blur
Double Vision	Itchiness
Burning/Dry Eyes	Redness
Secretion/Pus	Pain
Floating Spots	Squinting
Eye Strain/ Tired Eyes	Light Flashes

Any Additional Information?:

Personal Eye History

Styes	Eye Infection
Injury	Double Vision
Surgery	Color Blindess
Lazy Eye	Glaucoma
Pink Eye	Macular Degeneration
Cataracts	Other Problems

Any Additional Information?:

Personal Health History

My health history is negative for all the following.

General System
Fever, Weight Loss/Gain

Skin
Eczema
Melanoma

Neurologic
Headaches
Migraines
Seizures
Dizziness

Endocrine
Thyroid/Other Glands

Ears, Nose, Throat
Allergies/Hayfever
Sinus Congestion
Dry Throat/Mouth

Respiratory
Asthma
Chronic Bronchitis/Emphysema
Tubeculosis

Immunologic
Autoimmune conditions

Cardiovascular
Diabetes
High blood pressure
High cholesterol
Heart/Vascular disease

Gastrointestinal
Stomach/Intestines

Genitourinary
Kidney/Bladder/Genitals

Musculoskeletal
Rheumatoid Arthritis
Muscle/joint pain

Blood/Lymph
Anemia/bleeding problems
Infectious diseases

Psychiatric
Depression/Anxiety

Other
Pregnant/or Nursing
History of Cancer

Additional Information:

Systemic Medications: No Current Medications

Eye Medications: No Eye Medications

Allergies: No Known Drug Allergies

Family History

Macular Degeneration	Glaucoma	Lazy Eye
High Blood Pressure	Blindness	Diabetes
Melanoma Cancer	Color Blindness	Other

Additional Information:

Do you wear contacts?

Yes No Other

Are you interested in contacts?

Yes No Other

Are you interested in refractive surgery? (LASIK/PRK)

Yes No Other

(If yes, please fill out the contact history section below.)

Contact Lens History

How often do you wear your contacts?	daily weekends 1-2x/month Other
Wear time today: (# of hours)
Time you put your lenses on (on avg):
Time you remove your lenses (on avg.):
Average wear time (hrs)
Age of Lenses
Repl Sched:	daily 2 week monthly quarterly 6 months yearly Other

(scale of 10, 1=poor, 10=excellent)

Initial Comfort:		Comfort right before removal:
Overall Performance:

Contact Lens Solution:	BioTrue Blink Boston Boston Advance Boston Simplus ClearCare Menicon Optimum Pure Moist Refresh Refresh Plus Revitalens Unisol Other
Do you rub when cleaning your contacts?	Yes No Sometimes Other
Rewetting drops used?	Yes No Rarely Daily Other	Type used?	Blink for Contacts Opti-free rewetting unknown Other
Do you sleep in your contacts overnight?	no yes, occasional yes, 1 month Other

Social History

Recreational Drugs:	No Yes Other
Alcohol Use:	No Yes occasionally socially Other
Smoking Status:	never smoker current every day smoker current some days smoker current status unknown former smoker smoker unknown if ever smoked Other

COVID-19 SCREENING

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition	Yes	No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact
With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared
For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact
With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis,
Or Have You Been Asked To Quarantine?

Patient Signature:    Date:

Financial And Office Policy

Financial And Office Policy

- Most insurance policies pay only a portion of total charges. Questions about coverage should be directed to the appropriate insurance / benefits representative. Coverage information provided by the insurance company should be used as an outline only, we cannot guarantee its accuracy. Final financial responsibility is the patient's, not the insurance company's.

- In certain situations we may file forms for select types of insurance so that the patient may ovtain direct reimbursement, but he or she will still be reponsible for the charges incurred.

Important for contact lens wearers: Some contact lens related items and services may not be completely or even partially covered by insurance benefits. For example, the Annual Contact Lens Examination is not covered by most insurance examination benefits. Contact lens fittings may also not be covered.

- In addition, contact lens prescriptions for new contact lens wearers will only be released to patients after the mandatory Contact Lens Examination and only after a period of three to six months (at the doctor's discretion) to finalize the accuracy of the prescription.

I have read and agree to abide by office policy. I understand that payment is expected at the time services are rendered, and that I may be asked to pay in full on ordered items.

Patient Signature:    Date:

Notice Of Privacy Policies

Receipt of Notice of Privacy Policies & Consent

In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services and to conduct health care operations involving our office.

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; (2) our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; (3) our submission of your health information to auditors hired by third-party payers and insurers; and (4) other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office.

When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services and to perform healthcare operations. You also signify that you have received a copy of our Notice of Privacy Practices.

You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or healthcare operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I certify that the information given by me in applying for insurance is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and I authorize payment of these benefits directly to Dr. Patricia Chang Optometric Group, Inc on my behalf for any services and materials furnished. If I have other health insurance coverage, my signature authorizes release of the above medical information to the insurer or agency shown and authorizes my doctor to act as my agent as above.

I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that I have received the Notice of Privacy Practices from Dr. Patricia Chang Optometric Group, Inc.

Signature Patient/Legal Representative:
Date:

If signing as a legal representative, describe the relationship to patient and source of authority.

Source of Authority/Relationship to Patient:
Telephone:
Legal Representative Address:

Submit Data