Patient information

Primary Medical Insurance

Secondary Medical Insurance / Medical Supplement Plan

Primary Vision Plan

Secondary Vision Plan

Fields marked with * are required

Medical History

Please choose from the menu options

Eye History

Online Patient Forms

Fields marked with * are required

First name*

Last name*

Address*

City*

State*

Zip Code*

Cell Phone*

Email*

Date of birth*

Last 4 of SSN*

Billing to Insurance All insurance information must be submitted within 24 hours of scheduling your appointment.
Fill out all information below or text photos of your insurance cards, front and back, to (515) 512-1444 via HIPAA secure line.
Information not provided within this time period will not be eligible for insurance submission by Premier Vision Clinic.
If you do not have insurance or wish to private pay, select 'None'.

Insurance Information

Insurance Name*:

Insurance ID:

Insurance Information

Insurance Name*:

Insurance ID:

Insurance Information

Insurance Name:

Insurance ID:

Insurance Policy Group:

Insurance Information

Insurance Name:

Insurance ID:

Insurance Policy Group:

Describe (type, when were you diagnosed, etc)

*Hypertension

*Cardiovascular

Check the box for any conditions that apply to you, your parents or siblings:

If YOU are diabetic, when were you diagnosed?

Last A1C level?

*List all Rx and over-the-counter medications you currently take

*List any vitamins or supplements you currently take

*List any drug allergies you have

*Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Check the box for any conditions that apply:

*List any major eye injuries, infections or surgeries and approx dates

List any other significant eye problems you have had

List all Rx and over-the-counter eye medications you currently use

Please review information regarding services offered at your upcoming exam, understanding your vision and medical benefits, as well as our financial and cancelation policies on our website under the patient resources tab.

https://www.premiervisionclinic.com/patient-resources/

What to expect at your exam.

Understanding your Benefits