Online Patient Forms

Patient information

First name

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Last name

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Preferred name

Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

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Preferred Contact Method

Birthday

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SSN

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Occupation

Employer/School Name

Primary Vision Insurance

Insurance Information

Insurance Name:

Insurance ID:

Are you the Primary Policy holder on the insurance policy? Yes No

Primary On Account:

Please fill out the primary policy holder's information below

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

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Primary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Are you the Primary Policy holder on the insurance policy? Yes No

Primary On Account:

Please fill out the primary policy holder's information below

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Personal History

How did you hear about us?

If Referred By A Friend Or Family Member, Whom May We Thank For The Referral?

Date of Last Eye Exam

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Name of Previous Eye Doctor

Currently Wear Glasses?

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Currently Wear Contact Lenses?

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Are you considering new eyewear today?

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If you are a good candidate for contact lenses would you like to know?

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Are you interested in Learning more about Sports vision Training?

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Do You Have Prescription Sunglasses?

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How many hours do you spend on a digital device per day?

Hobbies / Special Visual Needs:

Favorite Music Genre / Artist?

Are you interested in Corrective Surgery?

What Concerns if any Do you Have with your current eyewear?

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Reason's For Visit (Please Select All That Apply)

VISION Complaint

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MEDICAL Complaint

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Ocular History: Review Of Systems

*This Section is Required

Have YOU or anyone in your IMMEDIATE FAMILY ever been diagnosed with an Ocular Condition?

Myself	Family	Condition
		Glaucoma
		Macular Degeneration
		Cataracts
		Dry Eyes
		Lazy Eye
		None
		Other

Personal Ocular History - additional:

Medical History

Have YOU or anyone in your IMMEDIATE FAMILY ever been diagnosed with a Medical Condition?

Myself	Family	Condition
		High Blood Pressure
		Diabetes
		Arthritis
		Cancer
		Multiple Sclerosis
		Thyroid Disease
		None
		Other

Please list any medication allergies you may have.

Please list all current medications.

Name of Primary Care Physician

Social History

Smoking Status

Alcohol Use

Please remember to bring the following items with you to your exam:

Vision and Medical Insurance Cards

Copy of previous prescriptions (if available)

Current Glasses - distance, reading, sunglasses, and computer glasses

Current Contact Lens Prescription (a photo of the numbers on the boxes will work)

List of current medications

Any drops you are currently using

Patient Signatures

Retinal Photo and 3D OCT Scan:

We believe checking your Eye Health is just as important as checking your Vision. This non-invasive test plays a major role in early detection and monitoring of many eye diseases such as diabetes, glaucoma, macular degeneration and retinal detachments. These conditions can lead to serious problems, including loss of vision or blindness. Many ocular conditions often develop without warning and can progress with no symptoms, as there are no pain receptors in the back of the eye. These retinal images become a permanent part of your medical record and will allow our doctor to monitor and track the health of your eyes on an annual basis. It is our office policy for this procedure to be performed on All Patients. The retinal screening fee is $39. The fee is included in our private pay pricing, but insurance plans typically do not cover this screening. (Pupil dilation may still be required.)

HIPAA Compliance Patient Consent Form

Notice of Privacy Practices: I acknowledge, by my signature below that I have been given the opportunity to review the Notice of Privacy Practices for Russell Liles, OD, PLLC and I understand that I may request a copy of this notice should I so choose.

Financial Agreement: I understand my insurance company may make payment directly to Russell Liles, OD, PLLC for services and/or materials rendered. I understand that Russell Liles, OD, PLLC may release information about me or my dependents necessary to process any and all claims for reimbursement on my behalf.

Authorization to Treat: I authorize Russell Liles, OD, PLLC, its agents, and employees (collectively referred to as "healthcare providers") to furnish optometric care and services, including but not limited to, diagnostic tests, examinations, and other medical and/or surgical procedures which is deemed necessary in the course of my care.

I understand and agree to decline pupil dilation today. If any condition arises in the future which may have been detected by pupil dilation, I will not hold Dr. Liles or his staff responsible.

Patient Signature

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Date