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

For All Sections That Are Required. Please Type None Or N/A To Submit.

City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday (Must be in XX/XX/XXXX) Occupation
Sex Employment Status
Marital Status Employer / School Name

Billing Information

If the billing address is different fill out the information below:
City: State: Zip Code:
Home Phone:
Work Phone:

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: A1C:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:

Family Medical History

Does anyone in your family have any of these medical conditions? If yes, please describe:

High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:

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:

Social History

Hobbies: STD's:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity:

Submit Form

Electronic Signature Agreement: By typing your name below, you are signing electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By typing your name below using any device, means or action, you consent to the legally binding terms and conditions of the corresponding policies. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Woodland Family Eye Care.

AUTHORIZATION TO RELEASE INFORMATION TO YOUR INSURANCE COMPANY AND ACKNOWLEDGEMENT OF PERSONAL RESPONSIBILTY FOR PAYMENT I hereby assign all medical and/or vision benefits (to which I am entitled) to the doctor caring for me. This includes major medical benefits, Medicare, private insurance, health and vision plans in which I am enrolled. This assignment will remain in effect until revoked by me in writing. I understand that I am financially responsible for all charges whether or not they are paid by my insurance. I hereby authorize the holder of my medical and patient registration records to release any information needed to process my insurance claims. I understand that all balances must be paid in full within 30 days. A copy of my medical records can be requested in writing and will be provided to me.

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By signing below, I acknowledge that I have received and read the Privacy Notice and Electronic Signature Agreement.

Signature: Date: