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


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 Patient Referral

Billing Information

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

Medical Insurance Information

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group Number:
Not Primary on Account:
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Insurance Information

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group Number:
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!

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:
Cancer:
Other:

Family Medical History



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

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

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:
Immune:

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 / Signatures


Emergency Contact and Record Release



I, , Authorize Seabert Eye Care to RELEASE my prescription and or eyeware to the following:

Name / DOB: Name / DOB:
Name / DOB: Name / DOB:

If your emergency contact is not listed above please designate below:

Name / Phone:

This authorization is considered valid for a period of 1 year.

The office, its employees, officers and attending physicians are released from legal responsibility or liability for the release of the requested information to the extent indicated and authorized herein.

Printed Name: Date:
Signature:


Financial Agreement



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

View Financial Agreement Policy

Patients Name:
Responsible Party (if not the patient):
Address:
Email:
Business Telephone: Cell Phone:
Home Telephone:
Signature: Date:
Co-Signature: Date:


Refraction, Assignment and Release, Acknowledgement of Notice of Privacy Practices (HIPPA) Policy



View Refraction, HIPAA, Assignment Policy

Refraction Policy



Signature: Date:

Assignment and Release



Signature: Date:

Acknowledgement of Notice of Privacy Practices (HIPPA)



Signature: Date: