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
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:
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
Polygamous
Widowed
Employer / School Name
Misc/Guardian
Gender
Referral
Billing Information
Is The Billing Address the 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
Accounts Management Services
Aetna
Ameren
American Family Mutual Insurance Company
American Heritage Life Insurance Company
American Republic Corp Insurance Company
Anthem Blue Cross Blue Shield
Assurant Health
BAS/HealthLink
Benefit Management, Inc.
BJC Healthcare
Blue Cross Blue Shield
Boilermakers National
Care Improvement Plus
Carpenters H&W/CMR
CBA
Cerner HealthPlan Services
Champva
Christian Brothers Service
Cigna
Continental Life Insurance
CoOportunity Health
CoreSource
Coventry Health Care
Cox Health Systems Insurance Company
Custom Network
Davis Vision
Dr. Timothy D. McGarity, M.D., P.C.
Encore
Equitable
Essence Healthcare
EyeMed Vision Care
EyeQuest
First Health
FMH Benefit Services, Inc.
FMH/HealthLink
GBS
GEHA Healthlink
Genworth Life Insurance Company
GHP Advantra
GHP ASO
GHP CoventryOne
Golden Rule Insurance Company
Great-West Healthcare
Group Health Plan
Guardian
Guideone Insurance Billing
GWH-CIGNA
Health Alliance
Health Net
HealthChoice
Healthe Exchange
HealthLink
HealthPartners
HealthScope
Healthsmart Benefit Solutions, INC
Horizon BCBSNJ
Hospital Services Group
HSI
Humana
Humana Vision Care Plan
Indiana Roofers/HealthLink
Leslie & Associates Benefit Alliance
LifeShield
Manhattan Life
Medco
Medi-Share
Medica Insurance Company
Medico Insurance Company
Medtrak
Mercy Health Plan
Meritain Health
Met Life
Mid-West National Life Insurance Co
Missouri Care Health Plan
MO Health Net
MoDOT/MSHP
Moyes Eye Center
Mutual of Omaha
National Vision Administrators, LLC
Opticare
Prairie States Enterprises, Inc
Principal Financial Group
Principal Life Insurance
PT Employer
Restoration Eye Care
Security Life
Spectera
StarMount Life Ins
Superior Vision
The Mail Handlers Benefit Plan
TLC
TransAmerica
Tricare
UMR
United Health Care
University of Missouri
USAA Life Insurance Company
Vision Service Plan
Welfare Fund of Engineers 513
WMHA
WPS Medicare
z
z-United Healthcare
zAARP Health Care Options
zAetna Global Benefits
zAetna One Tampa
zAetna.
zAlwaysCare
zAnthem
zAnthem BCBS
zAnthem Blue Preferred Plus
zAPWU Health Plan
zAR Benefits
zAR Health
zAssurant Health - 2806
zAssurant Health PHCS
zAVMA Group Health & Life Insurance
zAVMA Group Health & Life Insurance Tr
zBankers Life and Casualty Company
zBlue Cross Blue Shield of Illinois
zBlueCross BlueShield of Kansas
zBlueCross BlueShield of Kansas City
zBSBS
zCIGNA Health & Life Insurance Company
zCigna International
zConnecticut General Life Insurance
zCoventry
zCoventry Health Care Medical
zCoventry Healthcare
zCoventry National Network
zCoventry of Missouri
zCross Blue Shield Federal
Zenith Administrators Inc
Zenith/HL
zGolden Rule Insurance Co
zHealthlink Open Access II/CBS
zHealthSCOPE Benefits, Inc.
zHumana
zHumana One
zMedicare Part B
zPrincipal Life Insurance Company
zTricare Reserve Select
zTricare South Region
zUHC - 30557
zUMR
zUMR/HL
zUnited Healthcare
zUnited Healthcare International
zUnited Healthcare Vision Claims Depart
zUnitedHealthcare
zWPS
zWPS Health Insurance
zzAvesis
zzEmpire BlueCross BlueShield
zzEyeQuest Vision Insurance
zzUHG
zzUnited Healthcare
zzUnitedHealthcare
zzzUnited Healthcare International
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
Insurance Information
Insurance Name:
None
AARP
Accounts Management Services
Aetna
Ameren
American Family Mutual Insurance Company
American Heritage Life Insurance Company
American Republic Corp Insurance Company
Anthem Blue Cross Blue Shield
Assurant Health
BAS/HealthLink
Benefit Management, Inc.
BJC Healthcare
Blue Cross Blue Shield
Boilermakers National
Care Improvement Plus
Carpenters H&W/CMR
CBA
Cerner HealthPlan Services
Champva
Christian Brothers Service
Cigna
Continental Life Insurance
CoOportunity Health
CoreSource
Coventry Health Care
Cox Health Systems Insurance Company
Custom Network
Davis Vision
Dr. Timothy D. McGarity, M.D., P.C.
Encore
Equitable
Essence Healthcare
EyeMed Vision Care
EyeQuest
First Health
FMH Benefit Services, Inc.
FMH/HealthLink
GBS
GEHA Healthlink
Genworth Life Insurance Company
GHP Advantra
GHP ASO
GHP CoventryOne
Golden Rule Insurance Company
Great-West Healthcare
Group Health Plan
Guardian
Guideone Insurance Billing
GWH-CIGNA
Health Alliance
Health Net
HealthChoice
Healthe Exchange
HealthLink
HealthPartners
HealthScope
Healthsmart Benefit Solutions, INC
Horizon BCBSNJ
Hospital Services Group
HSI
Humana
Humana Vision Care Plan
Indiana Roofers/HealthLink
Leslie & Associates Benefit Alliance
LifeShield
Manhattan Life
Medco
Medi-Share
Medica Insurance Company
Medico Insurance Company
Medtrak
Mercy Health Plan
Meritain Health
Met Life
Mid-West National Life Insurance Co
Missouri Care Health Plan
MO Health Net
MoDOT/MSHP
Moyes Eye Center
Mutual of Omaha
National Vision Administrators, LLC
Opticare
Prairie States Enterprises, Inc
Principal Financial Group
Principal Life Insurance
PT Employer
Restoration Eye Care
Security Life
Spectera
StarMount Life Ins
Superior Vision
The Mail Handlers Benefit Plan
TLC
TransAmerica
Tricare
UMR
United Health Care
University of Missouri
USAA Life Insurance Company
Vision Service Plan
Welfare Fund of Engineers 513
WMHA
WPS Medicare
z
z-United Healthcare
zAARP Health Care Options
zAetna Global Benefits
zAetna One Tampa
zAetna.
zAlwaysCare
zAnthem
zAnthem BCBS
zAnthem Blue Preferred Plus
zAPWU Health Plan
zAR Benefits
zAR Health
zAssurant Health - 2806
zAssurant Health PHCS
zAVMA Group Health & Life Insurance
zAVMA Group Health & Life Insurance Tr
zBankers Life and Casualty Company
zBlue Cross Blue Shield of Illinois
zBlueCross BlueShield of Kansas
zBlueCross BlueShield of Kansas City
zBSBS
zCIGNA Health & Life Insurance Company
zCigna International
zConnecticut General Life Insurance
zCoventry
zCoventry Health Care Medical
zCoventry Healthcare
zCoventry National Network
zCoventry of Missouri
zCross Blue Shield Federal
Zenith Administrators Inc
Zenith/HL
zGolden Rule Insurance Co
zHealthlink Open Access II/CBS
zHealthSCOPE Benefits, Inc.
zHumana
zHumana One
zMedicare Part B
zPrincipal Life Insurance Company
zTricare Reserve Select
zTricare South Region
zUHC - 30557
zUMR
zUMR/HL
zUnited Healthcare
zUnited Healthcare International
zUnited Healthcare Vision Claims Depart
zUnitedHealthcare
zWPS
zWPS Health Insurance
zzAvesis
zzEmpire BlueCross BlueShield
zzEyeQuest Vision Insurance
zzUHG
zzUnited Healthcare
zzUnitedHealthcare
zzzUnited Healthcare International
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
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?:
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:
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
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
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
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