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:
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:

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: 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: 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: Disposable:

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:

Family Eye / Medical History

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

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


Family Medical History:

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:

Submit Form / Policies



FINANCIAL AGREEMENT/HIPAA DISCLOSURE/PHI CONSENTS



I authorize the release of medical information necessary to process for/and payments of vision/medical benefits to the practice of Specs Appeal/T&T Eyecare, LLC. I understand I am responsible for all charges whether paid by my vision/medical plan or not. For those carriers that we do not participate, payment will be due at the time of service. Participating carriers are to process and pay claims correctly within 31 days of submission, at which time, all outstanding balances become the responsibility of the patient/guardian. In the event we do not file with your major Medical Insurance or Vision plan, we can provide you with an itemized receipt for your year-end tax purposes. I understand there are no refunds on customized orders and a 50% restocking fee on all others if returnable otherwise. My signature below also gives consent to charge any credit/debit card should I not be present with the card. I also acknowledge the receipt of notice of privacy practices, and my signature below verifies HIPAA disclosure, and gives consent for all (e)PHI information transmittal. A scanned/photocopy of this agreement is to be considered as valid as the original. My signature below states that I have read and accept the above policies.



Signature of Patient/Guardian: Date: