Online Patient Form

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Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone:
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 Different?
TitleFirstLastMISuffix
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:

Vision Plan

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


Patient Signatures

DILATION, FUNDUS, AND VISUAL FIELDS:

Dilated Fundus Exam: enables the doctor to provide a more thorough ocular health analysis. With the dilated pupils, the doctor gets a better view inside the eyes that allows for early detection of ocular pathologies such as retinal holes, tears, detachments, tumors, or abnormal blood vessels. A Dilated Fundus Exam is extremely essential for individuals with diabetes, hypertension, age-related macular degeneration and glaucoma. The side effects are blurred at near and light sensitivity for up to 12 hours. In some individuals, the distance vision may also be blurred. However, you do have the option to have the fundus photo (Retinal Imaging) done which will have no side effects.

Yes, I do want the DILATED FUNDUS EXAM $30.00

Yes, I do want the FUNDUS PHOTO (Retinal Imaging) $39.00

Visual Field Analyzer: is a highly computerized instrument that provides the doctor a more thorough analysis of your field of vision. Visual Field Screening can assist in early detection of glaucoma, retinal pathologies from hypertension and diabetes and some neurological diseases.

YES, I do want the VISUAL FIELD SCREENING $25.00

NO, I do not want the VISUAL FIELD SCREENING

WE ARE COMMITTED TO EARLY DETECTION AND PREVENTION OF EYE DISEASES. WE STRONGLY RECOMMENDED THAT ALL OF OUR PATIENTS RECEIVE BOTH TESTS AS A PART OF THEIR COMPREHENSIVE VISUAL ANALYSIS

I understand that without these test certain eye disease and conditions may not be discovered. I agree to assume all risks associated with refusing these tests, indemnify, hold harmless, and release Momin VisIon Care, its employees and optometrists, from any claims or liability whatsoever related to failure to diagnosis and/or treat any eye condition due to lack of diagnostic information which could have been obtained by these tests.

ALL FEES PAID FOR PROFESSIONAL SERVICES ARE NON-REFUNDABLE AND PAYABLE AT THE TIME OF SERVICES.



No Changes Since Last Visit

Signature: Date:

** By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I accept has the same validity and meaning as my handwritten signature.

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

View Patient Privacy Policy

HIPAA: ACKNOWLEDGEMENT AT RECEIPT OF PRIVACY NOTICE

By signing this acknowledgement of Receipt of Notice of Privacy Practices (the "NOTICES"); I acknowledge and agree that I have received a copy and/or read a copy of the Notice of Privacy Practices for review and to keep for my records on the date identifies below. I understand that the office may use and disclose necessary person health information (for example: my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit the office to perform its administrative duties, provide me with eye care services and products, process my vision/medical benefit claims and communicate with me regarding vision/medical claims and communicate with me regarding vision/medical care services provided by the office (for example, mailings of exam reminders or information for services/product provided by the office). I can be assured that this office does not sell my personal health information of any kind to a third party for such party's own use. I authorize the office to submit my vision/medical benefit claims to my plan sponsor or health plan to receive reimbursement directly for the vision/medical services/product that I have received from the office.

Patient Signature or Patient's Legal Representative: Date:

INSURANCE SIGNATURE ON FILE:

I certify the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits and I authorize payment of these benefits directly to the doctor on my behalf for any services and material furnished. I authorize any holder of medical information about me to be release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. If I have other insurance coverage, my signature authorizes release of the above medical information to the insurer or agency shown, and authorizes my doctor to act as an agent, as above. I understand I am responsible for the balance of fees not paid by

Lifetime Patient Signature: Date:

REFRACTION POLICY:

During your visit, a refraction may be performed to determine your need for glasses or to evaluate if any further visual improvement can be achieved. This is necessary and essential portion of your eye exam and in some cases the sole reason for the appointment. The Centers for Medicare and some insurance companies consider a refraction to be a NON-COVERED service. Please be aware it is the responsibility of the patient to pay for the refraction unless otherwise stipulated by your insurance carrier. Our office currently charges $45.00 for this procedure, but provides a prompt pay price of $25.00 to the patient when paid at the time of service. The refraction fee is in additional to the eye exam and is in additional to the patient's copay.

I have read the above information and understand I may be charged a prompt pay price of $25 for refraction at the time of service unless otherwise stipulated by my insurance company.

Patient or Guardian's Signature: Date:

Consent Form

Please read the following statements and initial next to the following statements to indicate your agreement. If you cannot positively affirm to all these questions, you will be asked to postpone or reschedule your visit to a later date.

I do not currently, nor have I had in the last two weeks, a fever, cough, sore throat, loss of smell/taste, diarrhea, or other cold symptoms.

To the best of my knowledge, I do not have, nor have I been in direct contact with someone who has a confirmed diagnosis of COVID-19 or a presumptive positive COVID-19 test result in the last 30 (thirty) days

Neither I, nor anyone living in my immediate household have traveled outside of the state of Texas in the last 30 days

Neither I, nor anyone living in my immediate household have traveled outside of the US in the past 2 months

On March 16th, The Centers for Disease Control and Prevention (CDC) issued the following Public health Reminder:

Healthcare facilities and clinicians should prioritize urgent and emergency visits and procedures now and for the coming several weeks. The following actions can preserve staff, personal protective equipment, and patient care supplies: ensure staff and patient safety; and expand available hospital capacity during the COVID-19 pandemic.

    * Delay all elective ambulatory provider visits     * Reschedule elective and non-urgent admissions     * Delay inpatient and outpatient elective surgical and procedural cases     * Postpone routine dental and eyecare visits

I have read the above stated Public Health Reminder and have answered the health questions above honestly and to the best of my knowledge. I understand that Optiqueyes doctors and staff are taking precautions to limit any potential exposure I may have to the COVID-19 virus. I also understand that there is no definitive way to eliminate potential exposure by one hundred percent.

By signing this form below, I agree that I will not hold Optiqueye or any of its doctors or staff personal responsible should I, or someone I come in contact with, becomes positively or presumptively positive diagnosed with the COVID-19 virus. There are certain inherit risks associated with an eye exam during an epidemic and I assume full responsibility for personal illness that may result and further release and discharge Optiqueye and its doctors and staff for injury, loss or damage arising out of my visit. I understand that COVID-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.

Print Legal Name Signature Date

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