Online Patient Form
After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!
Patient Information
First
Last
MI
Suffix
Nickname
Address:
Apt/Suite #:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Cell Phone:
Email
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
Birthday
Occupation
Sex
Male
Female
Misc/Guardian
Insurance Information
Please list any vision AND medical insurance you have. Even if scheduling a vision exam, we may
need to perform additional tests that are considered medical to examine your eyes. THANK YOU!
Vision Insurance Information
Insurance Name:
None
Not listed below, please call us
Aetna (EyeMed)
BCBS
Cigna Vision
Davis Vision
EyeMed
EyeMed Discount Plan
Humana Medicare Advantage
Humana Vision (EyeMed)
IBEW-NECA
Medicare
Spectera
Superior Vision
TML IEBP
United Health Care
Vision Service Plan
Insurance ID:
Insurance Policy Group:
If the patient is NOT the primary on the insurance policy, please
provide the following for the primary on the insurance:
Primary on Account
Name:
Last, First, MI
Relationship to Insured:
Spouse
Child
Other
Birthday:
Last 4 digits of SSAN if VSP:
Medical Insurance Information
Insurance Name:
None
Not listed below, please call us
Aetna
BCBS
Cigna
GEHA
Golden Rule
Humana Medicare Advantage
Medicare
United Health Care
United Health Care All Savers
Insurance ID:
Insurance Policy Group:
If Medicare is your primary medical insurance, please provide the following
information regarding Medicare supplemental insurance (if any):
Insurance Name:
None
Not listed below, please call us
AFLAC
Allied Benefit Systems
American Continental Insurance Co
AMA
American Family Life Ins
American Insurance Admin
American Pioneer
American Retirement Life Ins
Americo
Arcadia Health Plan
Bankers Fidelity
Bankers Life & Casualty Co
Central United Life
Christian Fidelity Life Ins Co
Colonial Penn Life Ins
Continental Life
Equitable Life
Harvard Pilgrim
Liberty Health Share
Loyal American
Manhattan Life
Mercer Health
North American Administrators
Physicians Health Choice
Physicians Life
Physicians Mutual Ins Co
Provident American Life & Health
Smith Admin
Standard Life & Casualty Ins Co
State Farm
The Hartford
Tricare
UMR
USAA
WPS Health Insurance
Insurance ID:
Insurance Policy Group:
Eye History
You
Mom
Dad
Sibling
Grandparent
Additional Info
Glaucoma
Macular Degeneration
Retinal Detachment
Cataract
Lazy/Cross Eye
Please list any other eye conditions or past eye surgeries:
None
Please list any eye medication you're currently taking:
None
Medical History
You
Mom
Dad
Sibling
Grandparent
Additional Info
Hypertension
Diabetes
Thyroid Condition
Cancer
Heart Disease
Please list any other medical conditions or past surgeries:
None
Medications, Allergies, Other History
Please list any medications (over the counter and prescription) and vitamins you're taking:
None
Please list any medication or other allergies you experience:
None
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