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!

Demographics


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
AddressApt/Suite #
CityStateZipCode
Home Phone:
Work Phone:

Eye 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

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 CLs worn in past: Cleaner Wear Time Disposal

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:

Height
ft in
Weight
lbs


Do you have any of these medical conditions?:

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Hepatitis: If yes, what type?
HIV:
Tuberculosis:
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's

Submit / Signatures



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

Notice of Privacy Practices

View Notice of Privacy Practices Form

The law requires that Avery Ranch Eye Care make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:

I was given the opportunity to read, have read or had explained to me Avery Ranch Eye Care's Notice of Privacy Practice prior to any services offered.

The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible.

I authorize Avery Ranch Eye Care to release my personal health information to the following individuals:

   

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

Patient Signature: Date:

If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor.

Representative Signature:   Relationship To Patient: