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 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

**Click Here to View our Notice of Privacy Practices**

ACKNOWLEDGEMENT OF NOTIFICATION OF PATIENT'S RIGHTS TO PRIVACY

I acknowledge that I have been notified of ClearVision Centers Notification of Patient's Rights to Privacy.

Signature: Date:

To allow ClearVision Centers to discuss your medical condition, treatment plan, surgery plan, appointment
dates and times, etc. with a family member or other person involved in your health care, please list their
names and their relationship to you below. You are not required to list anyone.

I authorize ClearVision Centers to release health information identifying me to the family members or
other persons I have listed below:

Name: Relationship: Phone #:
Name: Relationship: Phone #:
Name: Relationship: Phone #:

FINANCIAL ASSIGNMENT AND AGREEMENT

Insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a
substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay
a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, and/or
any other balance not paid for by your insurance.

I request that payment of authorized Medicare and/or insurance benefits be made on my behalf for any
services furnished to me. I authorize any holder of medical information about me to release to the Health
Care Financing Administration, its agents, or any insurance carrier I may have, any information needed to
determine these benefits or the benefits payable for related services.

Signature: Date: