Online Patient Form

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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

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:
Primary Reasons: Secondary Reasons:

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: Last Appointment Type 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:

Medical History

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

Primary Care Physician: Pharmacy: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot: Recent Flu Immunization:


Do you have any of these medical conditions?:

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History



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

High Blood Pressure: Diabetes:
Thyroid Conditions: High Cholesterol:
Heart Conditions: Other:
Cancer:

Family Eye History

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

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:
Immune:

Social History

Occupation
Hours Of Screen Time Per Day?

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

Race: Ethnicity: Preferred Language:

Submit Form / Patient Signatures



Insurance Assignment/Financial Responsibility

There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts both:

     1. Vision Care Plans (such as VSP, MESC, EyeMed)
     2. Medical Insurance (such as Blue Cross/Blue Shield, Medicare)

     * Vision Care plans only cover routine vision exams along with eyeglasses and contact lenses.
     Vision plans only cover a basic screening for eye disease. They do not cover diagnosis,
     management or treatment of eye diseases.
     * Medical insurance must be used if you have any eye health problem or systemic health problem
     that has ocular complications. The doctor will determine if these conditions apply to you based
     upon your symptoms and case history.
     * If you have both types of insurance plans it may be necessary for us to bill some services to one
     plan and some to the other. We will use coordination of benefits to do this properly to minimize
     your out-of-pocket expense.
     * We will bill your insurance plan for services if we are a participating provider for the plan. We
     will try to obtain advanced authorization of your insurance benefits so we can tell you what is
     covered. Some fees may not be paid by your plan; we will bill you for any unpaid deductibles,
     co-pays or non-covered services as allowed by the insurance contract.


I request payment of authorized benefits be made on my behalf to Advanced Optometric Services for services rendered. I authorize any holder of medical information about me to release any information needed to determine these benefits related to services. I understand my signature below requests that payment be made and authorizes the release of information to the applicable insurer or agency.

I further understand that I am responsible to Advanced Optometric Services for any outstanding balance that may be left unpaid by my insurance company or paid to me by my carrier. I understand that I am responsible to pay for all services and materials rendered, including reasonable attorney’s fees and costs of collections in the event of any default.

I understand that if payment becomes thirty days past due, delinquency charges at $10.00 per month will be due from the date the payment was due.

Signature: Date:

HIPAA ACKNOWLEDGEMENT/CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
  • Obtaining payment from third party payers (e.g. my insurance company);
  • The day-to-day healthcare operations of your practice.


I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Pratices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Signature: Signature Date:
Relationship To Patient (if patient unable to sign):