Online Patient Form

Click here to return to the previous website.

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

How did you hear about us?:

Billing Information

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


IMPORTANT NOTICE: We require BOTH your medical insurance AND your vision plan information when scheduling
because many medical insurance plans have better patient benefits and can save you money. Vision plans only cover
a limited number of services. Many eye conditions and procedures are only covered by medical insurance.

Vision Insurance

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

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!

Eye Health

Reason for Visit:
Secondary Reasons:

Are You Currently Experiencing?:
Amblyopia/ Lazy Eye Blindness Crossed Eyes Cataracts
Glaucoma Macular Degeneration Retinal Disease Past Eye Injury / Infection
Double Vision Blurry Vision Visual Difficulty When Driving Distorted Vision / Halos
Flashes Of Light Black Spots Or Floaters Tired Eyes Dry Eye Sensation
Sandy / Gritty Feeling Burning Redness Tearing / Watering
Itching Mucous Discharge Eye Pain / Soreness Loss Of Vision
Light Sensitivity

Have you had any eye / Medical surgeries?:

Do you see blurry?: If blurry, which eye?: Is your blurry vision far or near?:
Are your eyes red?: When are your eyes red?:

Last Eye Exam:

Do You Wear? Glasses Contacts Lens
How Old Is Your Glasses Prescription
Contact Lens Brand?
Contact Lens Power?

Wants new glasses?: Back up glasses?: Back up sunglasses?:

Contacts Cleaner: Contacts Wear Time: Schedule Disposal:


Check ALL Conditions That Apply To You And Your Immediate Family Members?:

Autoimmune: Lupus Rheumatoid Arthritis Seasonal Allergies AIDS / HIV
Endocrine: Diabetes Type 1 Type 2 Hyperthyroid Hypothyroid Grave's Disease
Cardiovascular: High Blood Pressure Heart Disease Stroke / TIA
Dyslipidemia: High Cholesterol High Triglyceride
Respiratory: Asthma COPD Emphysema Bronchitis
Gastrointestinal: Crohn's Acid Reflux Inflammatory Bowel Disease
Genitourinary: Impotence Kidney Stones Frequent Urination
Hematologic: Anemia Bleeding Problems
Neurological: Seizures Paralysis Multiple Sclerosis Headaches Migraines Dizziness
Psychiatric: Anxiety Depression Alzheimer's Disease Bipolar Schizophrenia
Skin: Rosacea Growths Rashes Cancer
Ear, Nose, Mouth, Throat: Sinus Problems Hard Of Hearing Dry Mouth / Throat Chronic Cough
Bones, Joints, Muscles: Arthritis Joint / Muscle Pain Head And Neck Injury
Cancer: Yes No What Type?
Constitutional: Fatigue Weight Gain Weight Loss Fever


Other Conditions:

General History

Primary Care Physician: Primary Care Physician Phone #: Primary Care Physician Fax #:
Last Visit: Reason:

Please list all medications you're currently taking including eye drops:
Are you allergic to any medication?:
Do you take birth control?:
Over The Counter Medications:
Are you currently taking vitamins?:


Does anyone in your family have a history of any of the following?:

Social History

Pregnant Or Nursing: No Yes Not Applicable

Tobacco Use: No Yes Type: How Long
Alcohol Use: No Yes Type: How Long
Drug Use: No Yes Type: How Long

Have You Ever Been Exposed To Or Infected With Any Of The Following: HIV/AIDS Hepatitis Syphilis Gonorrhea TB COVID-19

Race: Ethnicity: Preferred Language:

Hobbies:

Submit Form / Signatures



Signature On File Form


HIPAA Privacy Acknowledgement


I have read and understand the Notice Of Privacy Practices. I understand that Griffin Eye Care is HIPAA compliant. I hereby acknowledge that the HIPAA policies are posted and available for me to read.

Patient Name (Print) Date
Patient / Guardian Signature

Note: This signature will remain on file indefinitely unless it is being revoked in writing.

Authorization To Release Medical Information


I consent to the use and disclosure of my information to only carry out treatments, payment activities, and submission of insurances. I have the right to allow the following person(s) acces to my Information and communicate with the staff at Griffin Eye Care on my behalf.

1) Relationship
2) Relationship

Patient / Guardian Signature:
Note: This signature will remain on file indefinitely unless it is being revoked in writing.

Assignment Of Benefit and Financial Responsibility


I, the undersigned, certify that I (or my dependent) have insurance converage and assign directly to Lien Tran Griffin OD PA (DBA Griffin Eye Care) all insurance benefits, if any, otherwise payable to me for services rendered. I understand that i am financially responsible for all charges whether or not paid by the insurance and that professional fees are non-refundable. I understance that my vision and/or health insurance coverage is a contract between myself and my insurance company and that it is ultimately myt responsibility as the patient to understand my insurance coverage as well as handle any charges my plan does not cover.

Patient / Guardian Signature