Online Patient Form | Ft Worth Office

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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

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

Billing Information

Is The Billing Address the Same?
City: State: Zip Code:
Home Phone:
Work Phone:

Medical History

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

Reason for Visit: Secondary Reasons:

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? If yes, please describe:

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

Family Medical History

Does anyone in your family have any of these medical conditions? If yes, please describe:

High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:

Eye History

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: 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:

Family Eye History

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:

Social History

Hobbies: STD's:

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

Race: Ethnicity: Preferred Language:

Submit Form

Electronic Signature Agreement: By typing your name below, you are signing electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By typing your name below using any device, means or action, you consent to the legally binding terms and conditions of the corresponding policies. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Advanced VisionCare.

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My signature below acknowledges that I have read and understand the Privacy Policies and Procedures for Advanced VisionCare, the offices of Dr. J. Kevin Smith O.D and Dr. Greg Frey O.D. I understand that I may download and/or print out a copy of the office policies for my own records on their website at:

I also give my consent for Advanced VisionCare to communicate with me using the following methods of communication:

Using mailing address on file

Signature of Patient/Representative: Date:
Name of Representative:

Signature on File Form

Responsibility Statement: Your insurance is a method for you to receive reimbursement for fees you have paid to the optometrist for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages based on your contract with them not with our office. It is your responsibility to pay in advance for the deductible, coinsurance, or any other balances not paid for by your insurance. We will assist you in receiving reimbursement as much as possible, but you are responsible in advance for your bill.

Financial Responsibility: By signing this statement you agree to be financially responsible for all charges.

Authorization to Release Medical Information: I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine benefits or the benefits payable for related services. This assignment will remain in effect until revoked in writing. A photocopy or electronic copy of this assignment is considered to be as valid as the original.

Signature: Date: