Online Patient Form

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev.

Address:
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:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Widowed	Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address Different? Yes

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address:
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:

Primary Insurance

Insurance Information

Insurance Name:	None AARP AARP UHC Medicare Complete AETNA AETNA Medicare AlwaysCare Avesis BCBS CapRock Health Plan Cigna Cigna/HealthPartners Colonial Penn Life Insurance Community Eyecare Davis Vision Emdeon EMIA EyeMed/ECPA GEHA HealthScope Humana InstaMed Medicare Medicare Railroad Medicare Supplement Medicare/Sec Misc Misc Medicare Supplemental Insurance Mutual of Omaha No Insurance PHCS Principal Sheet Metal Workers National Health Fund Spectera Superior Vision Tricare for Life UMR United Healthcare Unum Vision Vision Service Plan WellMed Medical Management
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None AARP AARP UHC Medicare Complete AETNA AETNA Medicare AlwaysCare Avesis BCBS CapRock Health Plan Cigna Cigna/HealthPartners Colonial Penn Life Insurance Community Eyecare Davis Vision Emdeon EMIA EyeMed/ECPA GEHA HealthScope Humana InstaMed Medicare Medicare Railroad Medicare Supplement Medicare/Sec Misc Misc Medicare Supplemental Insurance Mutual of Omaha No Insurance PHCS Principal Sheet Metal Workers National Health Fund Spectera Superior Vision Tricare for Life UMR United Healthcare Unum Vision Vision Service Plan WellMed Medical Management
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information

Insurance Name:	None AARP AARP UHC Medicare Complete AETNA AETNA Medicare AlwaysCare Avesis BCBS CapRock Health Plan Cigna Cigna/HealthPartners Colonial Penn Life Insurance Community Eyecare Davis Vision Emdeon EMIA EyeMed/ECPA GEHA HealthScope Humana InstaMed Medicare Medicare Railroad Medicare Supplement Medicare/Sec Misc Misc Medicare Supplemental Insurance Mutual of Omaha No Insurance PHCS Principal Sheet Metal Workers National Health Fund Spectera Superior Vision Tricare for Life UMR United Healthcare Unum Vision Vision Service Plan WellMed Medical Management
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Other

Insurance Information

Insurance Name:	None AARP AARP UHC Medicare Complete AETNA AETNA Medicare AlwaysCare Avesis BCBS CapRock Health Plan Cigna Cigna/HealthPartners Colonial Penn Life Insurance Community Eyecare Davis Vision Emdeon EMIA EyeMed/ECPA GEHA HealthScope Humana InstaMed Medicare Medicare Railroad Medicare Supplement Medicare/Sec Misc Misc Medicare Supplemental Insurance Mutual of Omaha No Insurance PHCS Principal Sheet Metal Workers National Health Fund Spectera Superior Vision Tricare for Life UMR United Healthcare Unum Vision Vision Service Plan WellMed Medical Management
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Are you a previous patient of Dr. Betty Vo's? How did you hear about our office?

Eye History

Reason for Visit:

Primary Reasons:	Secondary Reasons:

Do you currently have any of these symptoms?:	None Itching Burning, Stinging Red Floaters Flashes Of Light Eye Injuries Eye Surgery Amblyopia Strabismus Cataracts Glaucoma Retinal Disorders Other
Do you take any of these eye medications?:	None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other

Have you had any eye surgeries? Please describe:

Last Eye Exam:

1 year 2 years 3 years Other

Last Appointment Type

By Doctor:

Primary Vision Correction:

None Prescription Glasses Prescription Reading Glasses Soft Contacts Non-Prescription Reading Glasses Other

Do you:    Have back up glasses?

No Yes Other

Want new glasses?

No Yes Other

Want backup sunglasses?:

No Yes Other

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

Medical History

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Please describe any injuries or surgeries you have had:

Primary Care Physician:

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years greater than 3 years Other

Reason:

Check up Annual Specific Other

Pregnant Or Nursing:

Yes No Unsure Other

Recent Tetanus Shot:

Yes No Other

Recent Flu Immunization:

Yes No Other

Do you have any of these medical conditions?:

Diabetes:	No Yes	Year Diagnosed:
High Blood Pressure:	No Yes
High Cholesterol:	No Yes
Thyroid Conditions:	No Yes
Heart Conditions:	No Yes
Cancer:	No Yes

Other:

Review of Systems

General:	None Fatigue Fever Loss of Appetite Weight Gain Weight Loss Developmental Disorders Other	Ear/Nose/Throat:	None Neck Problems Sinus Problems Sore Throat (Recent) Headache Morning Headaches Migraine Headache Cluster Headache Hearing Loss Tinnitus Congestion Dry throat / mouth Sleep Apnea Other
Skin:	None Acne Lupus Dermatitis Eczema Psoriasis Rosacea Skin Cancer Itching Other	Cardiovascular:	None Congestive Heart Disease Cardiovascular Disease High Cholesterol Hypertension Arrhythmia Heart Murmur Heart Palpitation Chest Pain Arteriosclerosis Coagulation Disorder Mitral Valve Prolapse Low Blood Pressure Other
Respiratory:	None Asthma Cancer: lung Sleep Apnea Sarcoidosis COPD Emphysema Pneumonia Bronchitis Shortness of breath Wheezing Other	Musculoskeletal:	None Arthritis Osteoporosis Fibromyalgia Osteoarthritis Muscular Dystrophy Lupus Decreased range of motion Muscle cramps Pain/tenderness Stiffness Swelling Weakness Other
Psychiatric:	None Attention Deficit Disorder Anxiety Brain Damage (trauma) Panic Attacks Alzheimer's Disease Bi-polar Depression Insomnia Obsessive/Compulsive Paranoia Suicidal Violence Other	Gastrointestinal:	None Acid Reflux Crohn's disease Gastric reflux (GERD) IBS Ulcer Gall bladder problems Jaundice Hepatitis Sarcoidosis Cancer: colon Cancer: Liver Other
Endocrine:	None Crohn's disease Diabetes Type 1 Diabetes Type 2 Diabetes Suspect Hypothyroid Hyperthyroid Gout Hormone Replacement Therapy Other	Blood/Lymph:	None Anemia Hx of Significant Blood Loss Hematologic Disorder Sickle Cell Disorder Breast Carcinoma Lymph Node Disease Temporal Arthritis Cuts slow to clot Easy bruising Other
Neurological:	None Multiple Sclerosis Seizure Disorder Parkinson's Disease Brain Tumor Bells Palsy Dyslexia Headache Balance problems Vertigo Tremors Changes in senses Dementia Memory problems Muscle weakness Numbness, paralysis Personality changes Speech problems Other	Genitourinary:	None Amenorrhea Menopause Impotence Jaundice Uterine Cancer Prostate Cancer Kidney Stones Pregnant Nursing Syphilis Prostate Problems Bladder Infections STD- herpetic STD- chlamydia Other
Immune:	None Seasonal allergies Environmental allergies Food allergies Drug allergies (please specify) Sjogren's syndrome AIDS Herpes Simplex HIV Simplex Mononucleosis Tuberculosis Cytomegalovirus Infection Herpes Zoster Lyme Disease Sarcoidosis Syphilis Hives Itching Mild allergy symptoms Severe allergy symptoms Swelling Other

Social History

Hobbies:

None Art Baseball Astronomy Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Smoking Status:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	Type:	None Cigarettes Chewing Tobacco Other	How Long:
Alcohol Use:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drug Use:	No Yes Other	Type:		How Long

Race:	White Black or African American Asian Patient Declined to Specify American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Race Other	Ethnicity:	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other	Preferred Language:	English French German Spanish Other
STD	None Gonorrhea Syphilis Hepatitis HIV TB

Family Eye History

Does anyone in your family have any of these eye conditions?:

Macular Degen:	No Parents Siblings Grandparent Other	Glaucoma:	No Parents Sibling Grandparent Other
Retinal Detach:	No Parents Siblings Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other
Lazy/Crossed Eye:	No Parents Siblings Grandparent Other	Blindness:	No Parents Siblings Grandparent Other

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?:

High Blood Pressure:	No Parents Siblings Grandparent Other	Diabetes:	No Parents Siblings Grandparent Other
Thyroid Conditions:	No Parents Siblings Grandparent Other	High Cholesterol:	No Parents Siblings Grandparent Other
Heart Conditions:	No Parents Siblings Grandparent Other	Other:
Cancer:	No Parents Siblings Grandparent Other

INFORMED CONSENT & TREATMENT AUTHORIZATION
The law requires that we make every effort to inform you of your rights related to your personal health Information:
* I have read or had explained to me that the Notices of Privacy Practices for Betty Vo, O.D and agree to continue my care with Betty Vo, O.D under said terms
* I was given the opportunity but declined to read the Notice of Privacy Practices, for Betty Vo, O.D but wish to continue my car with Betty Vo, O.D under the terms of the privacy policies
* The notice of Privacy Practices could not be read due to the emergent nature of the care or the reason described as:

I hereby authorize Betty Vo, O.D to provide a diagnosis & optometric treatment to my child or me. I further authorize the release of Protected health information to additional physicians or optometrist in order to facilitate continuity of care. I have read & understand the above information & am signing this form voluntarily.
Patient Signature: Date:

AUTHORIZATION TO RELEASE HEALTH INFORMATION & ASSIGN BENEFITS
I authorize the release of all necessary Protected Health Information & assign all medical & vision benefits to Betty Vo, O.D. I also request that payment of authorized Medicare (if applicable) benefits be made on my behalf to Betty Vo, O.D. for any services furnished to me Betty Vo, O.D. I authorized any holder of medical information related benefits or the benefits payable to related services. I understand that my signature requests that payment be made & authorizes release of medical information necessary to pay the claim. If item 12 of the CMS 1500 claim form is completed, my signature authorized releasing of the information to the insurer or agency shown. In Medicare assigned cases, the supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, copay, and & non covered services. Copay & deductible are based upon the charge determination of the Medicare carrier. I understand that I am ultimately responsible for any bill incurred in this office. Should this account become delinquent, I will be responsible for any & all legal fees, court costs, and collection charges. There will be a service charge for each returned check. This authorization & assignment will remain in effect until revoked by me in writing. A photocopy of this authorization and assignment is to be considered as valid as the original. I request that you file my insurance & I have agreed to & completed all of the conditions listed above. I accept financial responsibility for all charges. I have read & understood this information & I am signing voluntarily.

Signature: Date:

FINANCIAL & INSURANCE FILING POLICY
All charges are your responsibility, whether or not your insurance company pays. Not all services are covered in all contracts. Some insurance companies arbitrarily select certain services they will not cover. We cannot become involved in disputes between you and our insurer regarding covered charges, deductible and copay. If your insurance company does not pay your claim within 30 days, it is your responsibility to contact them to expedite payment. If your insurance company refuses to pay, you are responsible for payment. Payment for copay and/or deductible is due at time of services are rendered. Canceled or rescheduled appointments are subject to a $35 fee if we do not receive 24 hours advance notice. In the event that refraction is not covered by your insurance you will be charged a fee in addition to our copay and or deductible.

Signature: Date:

Submit Form / Additional testing

EYE PUPIL DILATION
Dilation of the pupil is a common diagnostic procedure used by eye doctors to better examine the interior of the eye for sight threatening diseases such as glaucoma, cataracts, tumors, and retinal detachments. It allows a more thorough examination by making the field of view wider and by permitting the doctor to see more of the inside of the eye. To dilate the pupil, eye drops must be administered. Once your pupils are dilated, it is common to experience light sensitivity and blurred near vision for approximately 4 to 6 hours. In some individuals, the distance vision may also be blurred. During this time you must exercise caution when performing tasks that may present a risk of injury.

Automated Visual Fields
Measuring your visual fields allows us to detect any defects in your peripheral vision. You will sit in front of an instrument that will flash small lights in different locations. While staring at a central target, you will press a button when you see each light. Abnormal results may indicate eye diseases or central nervous system problems such as glaucoma, retinal disease, tumors, stroke, and other disorders.

Yes, I elect to have this test performed. $39 Fee(May be covered by your insurance)
No, I do not elect to have test performed.

OPTOMAP Retinal Screening
This non-invasive procedure allows the doctor to see a much broader and more detailed view of the retina than is possible with conventional methods. When review, the scan becomes a permanent part of your medical file, enabling the doctor to make important comparisons should potential vision threatening Conditions show themselves at a future examination. Your Doctor strongly believes that the Optomap Retinal Screening is an essential part of your comprehensive eye exam and prescribes it for all patients once per year.

Any questions you have about the Optomap Retinal Exam can be directed to your Doctor when he/she review the images with you during your exam.

Yes, I elect to have this test performed. $39 Fee(May be covered by your insurance)
No, I elect to have my eyes dilated instead.
No, I do not elect to have either the Optomap Screening nor the eye dilation performed.

Signature: Date:

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