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!

Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
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 Insurance

Primary Medical Insurance

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:

Secondary Medical Insurance

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:

Vision Insurance

Vision Plan 1

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:

Vision Plan 2

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:

Chief Complaints


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:

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:


Medical History


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Patient 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:
Pregnant Or Nursing: Recent Tetanus Shot: Recent Flu Immunization:


Do you have any of these medical conditions? If yes, please describe:

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

Family Medical History

Unknown family history

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

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

Social History

Hobbies: STD's:

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

Race: Ethnicity: Preferred Language:


Review of Systems


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:



Submit Data / Patient Signatures



Notice Of Privacy Practices

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

View Notice Of Privacy Practices Form

Patient Signature: Date:

FINANCIAL RESPONSIBILITY

I acknowledge that I am responsible for all charges for services and materials provided, including the amount not covered by insurance plans. All services and materials provided are due and payable at the time of service or order. I understand that my insurance policy is an agreement between me and my insurance company. If payment from my insurance company is insufficient to settle my bill in full, the remaining balance and payment will remain my responsibility. All monthly statements are due and payable within 30 days. Any outstanding balances, after 30 days will accrue at a 1.5% monthly late fee. If my account remains unpaid after 120 days and payment arrangements were not made prior, my account may be placed into collections or small claims court.

Signature:
Relation To Patient:
Date:


AUTHORIZATION TO ASSIGN INSURANCE BENEFITS

I authorize billing and payment of medical benefits to Laguna Eyes Optometry, P.C. and Slow the Game Down for all services rendered during my visit. I understand that I am financially responsible for all charges, whether or not theses are covered by my insurance. I authorize Laguna Eyes Optometry, P.C. and Slow the Game Down to release all information necessary to secure payment from my insurance company on my behalf.

Signature:
Relation To Patient:
Date:


Communication Preferences

Please provide best number/email: Is it okay to leave a voicemail at this number?

I approve Laguna Eyes Optometry, PC to communicate with the following people about my eyecare and/or release my products to the following people without prior authorization:

Name: Relationship:
Phone Number: Email:
Name: Relationship:
Phone Number: Email:
Name: Relationship:
Phone Number: Email:


Emergency Contact(This Person To Be Contacted In Medical Emergency.)

Name: Relationship:
Phone Number: Email: