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 Insurance Information

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
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!

Eye History

Reason for Visit: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Last Eye Exam: By Doctor:

Primary Vision Correction:

Contact Lens Wearers only
Type of contacts worn in the past: Disposal: Wear Time:

Medical History

Medications: Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Primary Care Physician Phone #: Fax #:

Preferred Pharmacy: Location: Phone #:

Pregnant Or Nursing:


Family Eye History

Please list any medical conditions that occur within your family:

Family Eye History

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

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye:

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:

Social History

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

Race: Ethnicity: Preferred Language:

Submit Form

Dr. Paul Pholvichitr
1509 N Zaragoza Rd.
El Paso, TX 79936
(915) 779-7355

Authorization for Release of Identifying Health Information

I authorize the professional office of my optometrist named above to release health information identifying me under the following terms and conditions:
  1. Detailed description of the information to be released:
  2. To whom may the information be released:
  3. The purpose(s) for the release (if the authorization is initiated by the individual, it is permissible to state "at the request of the individual" as the purpose, if desired by the individual):
  4. Expiration date or event relating to the individual or purpose for the release:
It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization.

If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office contact person listed at the top of this form.

When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.

Signature: Date:

If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:

Relationship: Source of Authority:

Dilated Fundus Exam

In addition to our comprehensive eye exam, we are pleased to offer our patients the option of having their eyes dilated. This procedure is the standard of care and is recommended by our doctors. With the dilated fundus exam, our doctors will have a more complete view of the interior of the eye and will be better able to assess the health of the eye and detect ocular diseases. This procedure requires the instillation of eye drops and a wait of approximately 20 minutes for the drops to take effect. Side effects of this procedure include blur at near and sometimes at distance for about 3-4 hours. Some patients to have difficulty driving after the procedure is done. You may wish to have someone drive you home. Your eyes will also be more sensitive to bright light for about 3 to 4 hours. We recommend wearing sunglasses after the procedure is done and will provide you with some if you don't have your own.

There is a nominal $20.00 charge for this procedure.

If you are pregnant or are taking any medications for a heart condition, please let our technicians know as dilation may not be advised in these cases. If you have other health problems such as diabetes, the doctor may strongly recommend the dilation.

Please check the appropriate box below indicating your preference and sign the form at the bottom. If the patient is a minor, the parent or guardian should sign. If you have any questions, our doctors or technicians will be happy to answer them.




Signature: Date: