Online Patient Form

Click here to return to the previous website.

After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
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/Guardian

Billing Information

(if different from the information listed above)
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary Vision

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 Vision

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:

Primary Medical

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 Medical

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

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Eye History

Reason for Visit:
Primary Reasons: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: Last Appointment Type By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Medical History

Medications: Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot: Recent Flu Immunization:


Do you have any of these medical conditions?:

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History



Does anyone in your family have any of these medical conditions?:

High Blood Pressure: Diabetes:
Thyroid Conditions: High Cholesterol:
Heart Conditions: Other:
Cancer:

Family Eye History

Does anyone in your family have any of these eye conditions?:

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Blindness:

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:

Social History

Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:
STD

Submit Form / Patient Signatures


Consent for Medical Treatment

I hereby authorize and request that Mission Vision provide such medical care and administer such diagnostic and/or therapeutic procedures and treatments as in the judgement of the optometrist in attendance are deemed necessary and advisable.

Signature: Date:

Dilation

Dilation of the eyes involves the use of eye drop medications to open your pupil. This is optional to patients over 14 years of age. Dilating the pupil widens the pupil's opening and allows your doctor to get a better view and provide you with a comprehensive eye exam. It is similar to getting a physical exam once a year. Dilation causes blurry vision at all distances, but especially at close distances such as the distance of a cell phone or computer. The effects of dilation last usually 4-6 hours in adults.

Mission Vision requires all children 14 and younger to be dilated on annual exams for glasses. Most children are unable to relax their eyes and understand the subtleties of refraction (the process of determining the glasses prescription). Dilation in children lasts approximately 12-24 hours.

Very rarely, medications used for dilation can cause side effects such as elevated blood pressure, palpitations and allergic reactions.

Please choose one of the following options:
I give permission to have my eyes dilated (included with the exam)
I am declining dilation at this time
I am declining dilation and opt for wide field imaging Zeiss Clarus ($30)


If you are declining dilation, please read the statement below:

I understand that the exam performed today will include a refraction and undilated exam only. Refraction is the measurement of the strength of glasses that a patient needs. It does not include a complete exam of the posterior (back of the eye) which includes the retina and optic nerve. This means that the medical conditions like retinal tears, detachments, masses and other conditions may be missed, which can lead to loss of vision or blindness. My doctor recommends a complete medical eye exam with dilation, but I am declining.

Signature:

Acknowledgement to Release Information and Review of Privacy Practices

I authorize the release of any medical information necessary to process this claim. I authorize Mission Vision to apply for benefits on my behalf covered services rendered by the physician's order. I request the payment from my insurance company be made directly to Mission Vision.

I have been given the opportunity to review this office's Notice of Privacy Practices, which explains how my health information will be used and disclosed. I understand that I am entitled to receive a copy of this documentation.

Please Click on the Below Link to View Privacy Practices


View Patient Privacy Policy

Signature: Date:

Patient Authorization for Release of Health Records to External Parties (optional)

I hereby authorize Mission Vision to release health information to the following individual(s)/entity(ies) via written, verbal, fax and/or email (please mark through the delivery methods you want excluded):

Name/Entity:
Name/Entity:

I understand that I may withdraw or revoke my permission at any time. If I withdraw my permission, my information may no longer be used or released for the reasons covered by this authorization. However, any disclosures already made with my permission are unable to be taken back. I may revoke this authorization by notifying Mission Vision in writing.

My treatment will not be based on the completion of this authorization for release of health records to external parties form. The information to be released by this authorization may be re-released by the person or organization that receives it and may no longer be protected by Federal or Texas privacy regulations.

I release Mission Vision from legal responsibility or liability for the disclosure of the records authorized by this form. I understand that this authorization is voluntary and that I may refuse to sign it. I will be provided a copy of this signed authorization, if requested. A photocopy of this authorization is as valid as the original.

Signature: Date:

COVID-19 Pandemic Essential Eye Exam and Treatment Consent Form

Please read the following statements and initial next to the following statements to indicate your agreement. If you cannot positively affirm to all these questions, you will be asked to postpone or reschedule your visit to a later date.

I do not currently, nor have I had in the last two weeks, a fever, cough, sore throat, loss of smell/taste or other cold symptoms.

To the best of my knowledge, I do not have, nor have I been in direct contact with someone who has a confirmed diagnosis of COVID-19 or a presumptive positive COVID-19 test result in the last 30 (thirty) days.

Neither I, nor anyone living in my immediate household, have traveled outside of the state of Texas in the last 30 days.

On March 16th, 2020, The Centers for Disease Control and Prevention (CDC) issued the following Public Health Reminder:

Healthcare facilities and clinicians should prioritize urgent and emergency visits and procedures now and for the coming several weeks. The following actions can preserve staff, personal protective equipment, and patient care supplies: ensure staff and patient safety; and expand available hospital capacity during the COVID-19 pandemic:
  • Delay all elective ambulatory provider visits

  • Reschedule elective and non-urgent admissions

  • Delay inpatient and outpatient elective surgical and procedural cases

  • Postpone routine eyecare visits


    • I have read the above stated Public Health Reminder and have answered the health questions above honestly and to the best of my knowledge. I understand that Mission Vision, its doctor and staff are taking precautions to limit any potential exposure I may have to the COVID-19 virus. I also understand that there is no definitive way to eliminate potential exposure by one hundred percent.

    By signing this form below, I agree that I will not hold Mission Vision or any of it doctor or staff personally responsible should I, or someone I come in contact with, become positively or presumptively positive diagnosed with the COVID-19 virus. There are certain inherent risks associated with an eye exam during an epidemic and I assume full responsibility for personal illness that may result and further release and discharge DLV and its doctors and staff for injury, loss or damage arising out of my visit. I understand that COVID-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.

    Signature: Date:

    Contact Lens Fitting Agreement (If applicable)



    I understand that the professional fee for fitting or refitting of contact lenses will be based on the lenses selected. The total fee will include a charge for the original fitting or refit, and the contact lenses themselves (including the kit, accessories, and instruction). Because the contact lenses are individually fit specifically to the measurements of each patient, I understand that the fees for the fitting and refitting of contact lenses will not be refunded. I am responsible for the fitting fee listed below which is due and payable today.

    Soft contact lens fitting fees range from $99-$119 for cash paying patients, but may differ for various insurance providers. Hard contact lenses or scleral lenses will vary in their fee schedule.

    If you are fitted with any type of contact lenses and the vision or comfort is not satisfactory, an appropriate change in the lenses can be made when possible. After 30 days, there will be no re-fits, returns or refunds on the lenses.

    It should be understood that in certain types of lenses, there is visual compromise due to the design of the lenses. In the case of monovision/multifocal contact lens designs, binocular vision is partially compromised, possibly reducing depth perception as well as peripheral vision. In addition, there is possibility that patients wearing multifocal/toric lenses will experience glare in dim/dark environments. In the case of opaque/colored contact lenses, vision in dim/dark environments may be reduced and peripheral glare may be noticed due to the color on the lenses. No other guarantee is expressed to implied. I understand and agree to the above.

    I have been warned of the signs and symptoms of infection. I have been advised and understand that if I develop a red/painful eye or notice any change in my vision while wearing he lenses, I should remove my lenses and contact my doctor's office immediately. I understand that the lenses need to be replaced at their manufacturer's suggested replacement schedule (daily, 2 weeks, monthly). . I understand failure to follow the above warnings can result in permanent loss of vision/blindness and/or serious damage to my eyes. I acknowledge having received a copy of the contact lens care guidelines.

    Signature: Date: