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:
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 / Patient Signatures



Contact Lens Exam

In accordance with Nevada State Law, a contact lens fitting is required to update/renew a contact lens prescription. Our fitting fees are as follows:

        * Standard/Spherical Fitting $59
        * Toric/Astigmatism $89
        * Multifocal/Monovision $109
        * Specialty/Hard/Hybrid $500


FIRST TIME WEARERS must successfully complete a contact lens training at the cost of $45. This appointment will be scheduled separately from exam date.

Would you like to receive/renew/update a contact lens prescription today?
(Please Check One)

YES NO


Eye Wellness Check

Our doctors recommend a comprehensive retinal health check with every eye exam. With the latest medical technology, they will be able to detect both ocular and vascular diseases, including: Glaucoma, Macular Degeneration, Cataracts, High Blood Pressure, Diabetes, and much more.

There are two options available to check the health of your eyes. Please select one:

OPTOS Wellness Scan - 3D Retinal Imaging technology, this option only costs $35 (price adjusted for current pandemic crisis, future prices may vary).
DILATION - Traditional health check by implementing eye drops and dilating the pupils. Effects of dilation last between 4 to 8 hours , includes blurred near vision and light sensitivity.

fees are due at time of service. The undersigned individual is responsible for any charges not covered by insurance. Accounts 90 days old are subject to collections. All eyeglass orders are non-refundable, as they are made to order.

Payment from my insurance is paid directly to Eye Care at Rhodes Ranch. I understand that any benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.

By signing below, I have read and understand the above posted policies. The Notice of Privacy Practices advises me of how my protected information may be used and disclosed by this office and how I may obtain access to and control this information. In addition to signing below, I hereby consent to use and disclose of my health information for the treatment purpose, payment activities, and health operations of the office. The Notice of Privacy Practices is offered in the reception area at my request.

I have read and understood this form. I am signing voluntarily. I authorize the disclosure of my health information as described above.

Print Patient Name: Date:

Patient / Parent Or Guardian Signature: