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

Billing Information

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

Vision Insurance Information

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
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:

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!

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:

Preferred Pharmacy:
Pregnant Or Nursing:


Family Medical History



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

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Last Eye Exam: By Doctor:

Primary Vision Correction:

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

Family Eye History

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

Review of Systems

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

Social History

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

Race: Ethnicity: Preferred Language:

Office Policies

Joyce L. Wong, OD, PC
7181 Westwind Dr. Ste. D
El Paso, TX 79912
(915) 833-1928

Authorization for Release of Identifying Health Information

I authorize the professional office of my optometrist named above to release health information identifying me under the following terms and conditions:
  1. Detailed description of the information to be released:
  2. To whom may the information be released:
  3. The purpose(s) for the release (if the authorization is initiated by the individual, it is permissible to state "at the request of the individual" as the purpose, if desired by the individual):
  4. Expiration date or event relating to the individual or purpose for the release:
It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization.

If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office contact person listed at the top of this form.

When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.

Signature: Date:

If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:

Relationship: Source of Authority:

Monaco Optos Retinal Imaging

We have a new and advanced diagnostic test that is far more accurate than dilation for detecting pathology in the eye. Early detection is crucial for retinal problems such as macular degeneration, glaucoma, retinal holes, retinal detachments and diabetic retinopathy. The advanced technology we will be using to take retinal images is the Monaco Optos. The time to evaluate the retina is instant. The exam is painless and allows a 200 degrees view of the entire internal health of the eye without drops.

This is a required test that is now the standard of care at Dr. Joyce Wong’s office.

This test is required in order to give Dr. Wong the information she needs to give the best quality care for each patient. The fee for this test is $25.00 and is not covered by vision insurance.

I understand the Monaco Optos retinal imaging test is the standard of care at Dr. Joyce Wong's office This is a required test in order to give the doctor the information she needs to give the best quality care for each patient. I also understand I will be responsible for paying the $25.00 fee out of pocket during my visit.

NOTE: Dilation Fundus Exams will be at the discretion of the doctor. Diabetic patients will still be dilated for the standard of care for their comprehensive eye exams.

APPOINTMENT CANCELLATION FEE

If you need to cancel your appointment we ask that you call or text our office within 24 HOURS of your scheduled appointment. If the appointment is not cancelled within the 24 HOUR period the patient will be charged a $25.00 fee.

I have read and understand the appointment cancellation fee

CONTACT LENS ORDER CANCELLATION/RETURN POLICY

We appreciate you purchasing your contact lenses at our office. If for any reason you choose to cancel your order or return your lenses, you will be charged a $25.00 restocking fee.

I have read and understand the contact lens order cancellation/return policy