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
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
Decline Texting:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian Who referred you to our office?

Billing Information

Is The Billing Address the Different?
Title First Last MI Suffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary 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 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:

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: 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

Hobbies:

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

Race: Ethnicity: Preferred Language:
STD

Speed Questionnaire

1. Report the type of SYMPTOMS you experience and when they occured:

SYMPTOMS At This Visit Within Past
72 Hours		 Within Past
3 Months
Dryness, grittiness, or scratchiness Yes No Yes No Yes No
Soreness or Irritation Yes No Yes No Yes No
Burning or Watering Yes No Yes No Yes No
Eye Fatigue Yes No Yes No Yes No


2. Report the FREQUENCY of your symptoms using the rating list below:
0 = Never, 1 = Sometimes, 2 = Often, 3 = Consistant

SYMPTOMS Frequency
Dryness, grittiness, or scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue


3. Report the SEVERITY of your symptoms using the rating list below:
0 = Never, 1 = Tolerable, 2 = Uncomfortable, 3 = Bothersome, 4 = Intolerable

SYMPTOMS Severity
Dryness, Grittiness or scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Lifestyle Index

This questionnaire is meant to help your doctor understand what you're experiencing on a regular basis - whether it's caused by your eyes, posture, stress, etc. Your reponses will help make sure you receive the best care possible.

How often do you experience any of the symptoms? fill in applicable circle. For example: 1, 2, 3, 4, 5

Headaches
• You get headaches of any severity each week (even just a dull ache counts)
• Your headaches tend to get worse later in the day.
1 2 3 4 5
Never Rarely Sometimes Very Often Always


Stiffness / Pain In Neck / Shoulders
You experience stiffness / tension in your neck / shoulders when you work at a computer or read (this might even be from your posture)
1 2 3 4 5
Never Rarely Sometimes Very Often Always


Discomfort With Computer Use
Your eyes get tired, burn, or get red easily when you work at a computer for long hours.
1 2 3 4 5
Never Rarely Sometimes Very Often Always


Tired Eyes
Your eyes feel increasingly fatigued / tired as the day goes on.
1 2 3 4 5
Never Rarely Sometimes Very Often Always


Dry Eye Sensation
Your eyes progressively feel more dry / sandy / gritty while working at the computer or reading.
1 2 3 4 5
Never Rarely Sometimes Very Often Always


Light Sensitivity
Bright / Strong lights (vehicle headlights, fluorescent lights etc.) bother you.
1 2 3 4 5
Never Rarely Sometimes Very Often Always


Dizziness
You experience dizziness, motion sickness, or vertigo.
1 2 3 4 5
Never Rarely Sometimes Very Often Always

COVID-19 SCREENING

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition Yes No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis, Or Have You Been Asked To Quarantine?

Submit Form / Patient Signatures



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

Notice of Privacy Practices

View Notice of Privacy Practices Form

Patient Signature: Date:

Optomap Retinal Exam

View Optomap Retinal Exam Form

Patient Signature: Date:

Financial Policy

View Financial Policy Form

Patient Signature: Date:

Contact Lens Agreement

View Contact Lens Agreement Form

Patient Signature: Date:


I authorize Envision Ghent Optometry to release my information regarding my care to:

Name: Relationship To Patient: Phone Number:

Signature Of Patient:

Emergency Contact Information- I authorize the following to be contacted in case of an emergency.

Name: Relationship To Patient: Phone Number:

Signature Of Patient:

Cancellation Policy

Please note, we are now requiring you to give us a 24 hours notice of cancellation. A $50 fee will be assessed for missed appointments. You will be required to pay the said fee before you are able to reschedule another appointment. We appreciate your cooperation in this matter.

Patient Signature: Date:

No Show Policy

Thank you for trusting Envision Ghent Optometry with your vision needs. When you schedule an appointment with Envision Ghent Optometry, we set aside enough time to provide you with the highest quality care. Should you need to cancel or rescheduled an appointment please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment. Please see our Appointment Cancellation/No Show Policy below:

Effective April 28, 2022, any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours' notice will be considered a No Show and charged a $50.00 fee.

Any established patient who fails to show or cancels/reschedules an appointment with no 24 hours' notice a second time will be charged a $50.00 fee.

If a third No Show or cancellation/reschedule with no 24-hour notice should occur the patient may be dismissed from Envision Ghent Optometry.

Any new patient who fails to show for their initial visit will not be rescheduled.

The fee is charged to the patient, not the insurance company, and is due at the time of the patient's next office visit or will be billed to your address. If this bill is left unpaid, a 30-40% collection fee will be added to the total and your bill will be sent to collections."

As a courtesy, when time allows, we make reminder calls for appointments. If you do not receive a reminder call or message, the above Policy will remain in effect. We understand there may be times when an unforeseen emergency occurs, and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our Office Manager, who may be able to waive the No Show fee. You may contact Envision Ghent Optometry Monday- Friday between the hours of 9AM and 5PM at the number below. Should it be after regular business hours Monday through Friday, or a weekend, you may leave a message.

I have read and understand the Medical Appointment Cancellation/No Show Policy and agree to its terms.

Name of patient or legal guardian
Signature of patient or legal guardian