Online Patient Form
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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:
Alerts:
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
Billing Information
Is The Billing Address the Same?
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 Name:
None
AARP
Acordia National
ACS Benefit Services, Inc.
Advantica Benefits
Advantra Freedom
Adventist Risk Management
AETNA
Aetna Medicare
Aetna Medicare
Aetna Vision
Allegiance Benefit Plan Management, Inc.
Alliant Health Plans, Inc.
Allied Benefit Systems
America's 1st Choice
American Healthcare Alliance
American National Life Insurance Company of Texas
American Pioneer Life Insurance Company
American Republic Insurance Company
Ameritas Life Insurance Company
Appalachian Benefit Administrators
APWU
Assurant Health
AV-MED
Bakery And Confectionery Union and
Bankers Fidelity
Bankers Life And Casualty Company
BCBS M Medicare Advantage
BCBS of GA (Medicare Advantage)
BCBS OF NC
BCBS OF NC Federal Program
BCBS OF NC STATE PLAN
BCBSM
Benefit Administrative System, LLC
Benefit Management Services, Inc
Benefit Support, Inc.
Boilermakers (Vision)
Boilermakers National Health & Welfare F
Capital Health Plan
Care First
Care Improvements Plus
Caremark
CHAMPVA
Cherokee Indian Hospital Authority
Cigna Healthcare
Cigna Healthcare
Cigna HealthCare (Vision)
Cigna Medicare Access
Colonial Penn Life Insurance Company
Combined Insurance Company Of America
Community Eye Care
Constitution Life Insurance Company
Continental General Insurance Company
Coresource
Coventry Health Care Plan
Cresent
CSI
Deseret Mutual
DMERC
Doug Sutton Ins. Services
Equitable Life & Casualty Ins. Company
EyeMed
Fiserv Health
Freedom Life
Gallagher Bassett Services
GEHA
Genworth Life and Annuity Insurance
Georgia Bankers Association Ins. Trust
GPM Health and Life Insurance Company
Greek Catholic Union
Guarantee Trust Life Insurance
Hartford Life and Accident Ins. Co.
Health Equity, Inc
Highmark Blue Cross Blue Shield
HOP Administration Unit
Humana Claims Office
Humana Gold Choice
Jail
John Alden
Kaiser Permanente
Lions Club
M.M.&P. Health & Benefit Plan
Medco Health Solutions Inc.
Medcost
Medicaid EDS
Medicare
Medico Insurance Company
Medicorp Life Insurance Corporation
Mediplus
MetLife
Midwest Operating Engineers Welfare Fund
Mutual Of Omaha
NALC Health Benefit Plan
NC Health Choice
New Era Life Insurance Company
NRECA
Operating Engineers Trust Fund
Oxford Life Insurance Company
PAI
PHYSICIANS MUTUAL INS CO
POMCO
Principal Life Insurance
Private Pay
RAILROAD MEDICARE
Retiree Medical Insurance Plan
SAMBA
Sedgwick
Services for the Blind
SMW+
Spectera
State Farm Health Insurance
Sterling Investors Life Insurance Company
Stirling & Stirling, Inc
Summit America Insurance
Superior Vision Services, Inc.
TCCC
Tennessee Valley Operating Engineers
The Mail Handlers Benefit Plan
The Prudential
Thrivent Financial
Thrivent Financial for Lutherans
Transamerica Life Insurance Company
TRICARE
UMR
UNIFORM MEDICAL PLAN
United American Insurance Company
United Health Care
United Health Care (GA)
United Health Care (Medicare)
United Health Care Medicare Solutions
United Teacher Associates Insurance Company
US Marshall Service
USAA Life Insurance Company
Veterans Administration
Vocational Rehabilitation Services of
VSP
Wells & West
Workers' Compensation
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 Name:
None
AARP
Acordia National
ACS Benefit Services, Inc.
Advantica Benefits
Advantra Freedom
Adventist Risk Management
AETNA
Aetna Medicare
Aetna Medicare
Aetna Vision
Allegiance Benefit Plan Management, Inc.
Alliant Health Plans, Inc.
Allied Benefit Systems
America's 1st Choice
American Healthcare Alliance
American National Life Insurance Company of Texas
American Pioneer Life Insurance Company
American Republic Insurance Company
Ameritas Life Insurance Company
Appalachian Benefit Administrators
APWU
Assurant Health
AV-MED
Bakery And Confectionery Union and
Bankers Fidelity
Bankers Life And Casualty Company
BCBS M Medicare Advantage
BCBS of GA (Medicare Advantage)
BCBS OF NC
BCBS OF NC Federal Program
BCBS OF NC STATE PLAN
BCBSM
Benefit Administrative System, LLC
Benefit Management Services, Inc
Benefit Support, Inc.
Boilermakers (Vision)
Boilermakers National Health & Welfare F
Capital Health Plan
Care First
Care Improvements Plus
Caremark
CHAMPVA
Cherokee Indian Hospital Authority
Cigna Healthcare
Cigna Healthcare
Cigna HealthCare (Vision)
Cigna Medicare Access
Colonial Penn Life Insurance Company
Combined Insurance Company Of America
Community Eye Care
Constitution Life Insurance Company
Continental General Insurance Company
Coresource
Coventry Health Care Plan
Cresent
CSI
Deseret Mutual
DMERC
Doug Sutton Ins. Services
Equitable Life & Casualty Ins. Company
EyeMed
Fiserv Health
Freedom Life
Gallagher Bassett Services
GEHA
Genworth Life and Annuity Insurance
Georgia Bankers Association Ins. Trust
GPM Health and Life Insurance Company
Greek Catholic Union
Guarantee Trust Life Insurance
Hartford Life and Accident Ins. Co.
Health Equity, Inc
Highmark Blue Cross Blue Shield
HOP Administration Unit
Humana Claims Office
Humana Gold Choice
Jail
John Alden
Kaiser Permanente
Lions Club
M.M.&P. Health & Benefit Plan
Medco Health Solutions Inc.
Medcost
Medicaid EDS
Medicare
Medico Insurance Company
Medicorp Life Insurance Corporation
Mediplus
MetLife
Midwest Operating Engineers Welfare Fund
Mutual Of Omaha
NALC Health Benefit Plan
NC Health Choice
New Era Life Insurance Company
NRECA
Operating Engineers Trust Fund
Oxford Life Insurance Company
PAI
PHYSICIANS MUTUAL INS CO
POMCO
Principal Life Insurance
Private Pay
RAILROAD MEDICARE
Retiree Medical Insurance Plan
SAMBA
Sedgwick
Services for the Blind
SMW+
Spectera
State Farm Health Insurance
Sterling Investors Life Insurance Company
Stirling & Stirling, Inc
Summit America Insurance
Superior Vision Services, Inc.
TCCC
Tennessee Valley Operating Engineers
The Mail Handlers Benefit Plan
The Prudential
Thrivent Financial
Thrivent Financial for Lutherans
Transamerica Life Insurance Company
TRICARE
UMR
UNIFORM MEDICAL PLAN
United American Insurance Company
United Health Care
United Health Care (GA)
United Health Care (Medicare)
United Health Care Medicare Solutions
United Teacher Associates Insurance Company
US Marshall Service
USAA Life Insurance Company
Veterans Administration
Vocational Rehabilitation Services of
VSP
Wells & West
Workers' Compensation
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:
Tertiary Insurance
Insurance Name:
None
AARP
Acordia National
ACS Benefit Services, Inc.
Advantica Benefits
Advantra Freedom
Adventist Risk Management
AETNA
Aetna Medicare
Aetna Medicare
Aetna Vision
Allegiance Benefit Plan Management, Inc.
Alliant Health Plans, Inc.
Allied Benefit Systems
America's 1st Choice
American Healthcare Alliance
American National Life Insurance Company of Texas
American Pioneer Life Insurance Company
American Republic Insurance Company
Ameritas Life Insurance Company
Appalachian Benefit Administrators
APWU
Assurant Health
AV-MED
Bakery And Confectionery Union and
Bankers Fidelity
Bankers Life And Casualty Company
BCBS M Medicare Advantage
BCBS of GA (Medicare Advantage)
BCBS OF NC
BCBS OF NC Federal Program
BCBS OF NC STATE PLAN
BCBSM
Benefit Administrative System, LLC
Benefit Management Services, Inc
Benefit Support, Inc.
Boilermakers (Vision)
Boilermakers National Health & Welfare F
Capital Health Plan
Care First
Care Improvements Plus
Caremark
CHAMPVA
Cherokee Indian Hospital Authority
Cigna Healthcare
Cigna Healthcare
Cigna HealthCare (Vision)
Cigna Medicare Access
Colonial Penn Life Insurance Company
Combined Insurance Company Of America
Community Eye Care
Constitution Life Insurance Company
Continental General Insurance Company
Coresource
Coventry Health Care Plan
Cresent
CSI
Deseret Mutual
DMERC
Doug Sutton Ins. Services
Equitable Life & Casualty Ins. Company
EyeMed
Fiserv Health
Freedom Life
Gallagher Bassett Services
GEHA
Genworth Life and Annuity Insurance
Georgia Bankers Association Ins. Trust
GPM Health and Life Insurance Company
Greek Catholic Union
Guarantee Trust Life Insurance
Hartford Life and Accident Ins. Co.
Health Equity, Inc
Highmark Blue Cross Blue Shield
HOP Administration Unit
Humana Claims Office
Humana Gold Choice
Jail
John Alden
Kaiser Permanente
Lions Club
M.M.&P. Health & Benefit Plan
Medco Health Solutions Inc.
Medcost
Medicaid EDS
Medicare
Medico Insurance Company
Medicorp Life Insurance Corporation
Mediplus
MetLife
Midwest Operating Engineers Welfare Fund
Mutual Of Omaha
NALC Health Benefit Plan
NC Health Choice
New Era Life Insurance Company
NRECA
Operating Engineers Trust Fund
Oxford Life Insurance Company
PAI
PHYSICIANS MUTUAL INS CO
POMCO
Principal Life Insurance
Private Pay
RAILROAD MEDICARE
Retiree Medical Insurance Plan
SAMBA
Sedgwick
Services for the Blind
SMW+
Spectera
State Farm Health Insurance
Sterling Investors Life Insurance Company
Stirling & Stirling, Inc
Summit America Insurance
Superior Vision Services, Inc.
TCCC
Tennessee Valley Operating Engineers
The Mail Handlers Benefit Plan
The Prudential
Thrivent Financial
Thrivent Financial for Lutherans
Transamerica Life Insurance Company
TRICARE
UMR
UNIFORM MEDICAL PLAN
United American Insurance Company
United Health Care
United Health Care (GA)
United Health Care (Medicare)
United Health Care Medicare Solutions
United Teacher Associates Insurance Company
US Marshall Service
USAA Life Insurance Company
Veterans Administration
Vocational Rehabilitation Services of
VSP
Wells & West
Workers' Compensation
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 Problems
Yes
No
What is the particular problem?
Does anyone in your family have this? If yes, who?
Glaucoma
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Cataracts
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Macular Degeneration
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Retinal Detachment
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Eye Turn
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Lazy/Crossed Eye
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
List any eye surgeries: (List what kind and when)
Describe any eye injuries:
Medical problems
Date of Physical Exam:
Physician's Name:
Dr. William Breedlove
Dr. Brian Mitchell
Dr. Charles Watras
Dr. Daniel Stroup
Dr. David Mock
Dr. Gary Roper
Dr. Jill Sonnenburg
Dr. Kathy Waggoner
Dr. Lynch & Johnson
Dr. Mary Wells
Dr. Robert Moreland
Dr. Robert Solomon
Dr. Teresa Heavner
Dr. Thomas Clayton
Dr. Glendon P. Rougeou
Dr. Linsday Patterson
Chatuge Family Practice
Peachtree Pediatrics
Tallulah Health Center
Sylva Pediatrics
Does not have one
Other
Yes
No
What is the particular problem?
Does anyone in your family have this? If yes, who?
Cancer
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Diabetes
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
High Blood Pressure
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Stroke
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Thyroid Disease
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Asthma
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Emphysema
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Heart Disease
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Kidney Disease
No one
Father
Mother
Grandfather
Grandmother
Brother
Sister
Son
Daughter
Aunt
Uncle
Other
Any problems with the following systems of your body?
Yes
No
What is the particular problem?
Head/Neck:
None
Migraines
Headaches
Other
Ear/Nose/Throat:
None
Allergies
Seasonal Allergies
Hay fever
Chronic cough
Dry throat
Dry mouth
Ear ache
Hard of hearing
Post-nasal drip
Runny nose
Sinus congestion
Other
Respiratory:
None
Asthma
Chronic Bronchitis
Congestion
Emphysema
Shortness of breath
Wheezing
Other
Gastrointestinal:
None
Acid Reflux
Ulcer
Other
Skin:
None
Growths
Rash
Eczema
Hives
Rosacea
Other
Muscles:
None
Muscle pain
Cramps
Swelling
Fibromyalgia
Other
Bones/Joints:
None
Arthritis
Rheumatoid arthritis
Joint pain
Stiffness
Other
Blood/Lymph:
None
Anemia
Bleeding
Cholesterol
Other
Psychiatric:
None
Bipolar
Anxiety
Depression
Insomnia
Other
Neurological Problems:
None
Seizures
Parkinson's
Other
STD's:
Hepatitis C
HIV
AIDS
Chlamydia
Other
List MAJOR illnesses and injuries: (What kind and when)
List any [non-optical] surgeries:
Do you use tobacco products?:
Yes
No
If yes, type/amount/how often:
Smoking Status:
Current every day smoker
Current some day smoker (not daily)
Former smoker (no longer smokes)
Heavy smoker (>10 cigs/day)
Light smoker (<10 cigs/day)
Never smoker (<100 cigs equiv)
Smoker (current status unknown)
Unknown if ever smoked
Other
Do you drink alcohol?:
Yes
No
If yes, type/amount/how often:
Do you use illegal drugs?:
Yes
No
If yes, type/amount/how often:
Preferred Language:
English
Spanish
French
Patient Declined to Specify
Abkhazian
Afar
Afrikaans
Akan
Albanian
Amharic
Arabic
Aragonese
Armenian
Assamese
Avaric
Avestan
Aymara
Azerbaijani
Bambara
Bashkir
Basque
Belarusian
Bengali
Bihari languages
Bislama
Bokm?l, Norwegian), Norwegian Bokm?l
Bosnian
Breton
Bulgarian
Burmese
Catalan; Valencian
Central Khmer
Chamorro
Chechen
Chichewa; Chewa; Nyanja
Chinese
Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic
Chuvash
Cornish
Corsican
Cree
Croatian
Czech
Danish
Divehi; Dhivehi; Maldivian
Dutch; Flemish
Dzongkha
Esperanto
Estonian
Ewe
Faroese
Fijian
Finnish
Fulah
Gaelic; Scottish Gaelic
Galician
Ganda
Georgian
German
Greek, Modern (1453-)
Guarani
Gujarati
Haitian; Haitian Creole
Hausa
Hebrew
Herero
Hindi
Hiri Motu
Hungarian
Icelandic
Ido
Igbo
Indonesian
Interlingua (International Auxiliary Language Association)
Interlingue; Occidental
Inuktitut
Inupiaq
Irish
Italian
Japanese
Javanese
Kalaallisut; Greenlandic
Kannada
Kanuri
Kashmiri
Kazakh
Kikuyu; Gikuyu
Kinyarwanda
Kirghiz; Kyrgyz
Komi
Kongo
Korean
Kuanyama; Kwanyama
Kurdish
Lao
Latin
Latvian
Limburgan; Limburger; Limburgish
Lingala
Lithuanian
Luba-Katanga
Luxembourgish; Letzeburgesch
Macedonian
Malagasy
Malay
Malay
Malayalam
Maltese
Manx
Maori
Maori
Marathi
Marshallese
Mongolian
Nauru
Navajo; Navaho
Ndebele, North; North Ndebele
Ndebele, South; South Ndebele
Ndonga
Nepali
Northern Sami
Norwegian
Norwegian Nynorsk; Nynorsk, Norwegian
Occitan (post 1500)
Ojibwa
Oriya
Oromo
Ossetian; Ossetic
Pali
Panjabi; Punjabi
Persian
Polish
Portuguese
Pushto; Pashto
Quechua
Romanian; Moldavian), Moldovan
Romansh
Rundi
Russian
Samoan
Sango
Sanskrit
Sardinian
Serbian
Shona
Sichuan Yi; Nuosu
Sindhi
Sinhala; Sinhalese
Slovak
Slovenian
Somali
Sotho, Southern
Sundanese
Swahili
Swati
Swedish
Tagalog
Tahitian
Tajik
Tamil
Tatar
Telugu
Thai
Tibetan
Tigrinya
Tonga (Tonga Islands)
Tsonga
Tswana
Turkish
Turkmen
Twi
Uighur; Uyghur
Ukrainian
Urdu
Uzbek
Venda
Vietnamese
Volap?k
Walloon
Welsh
Western Frisian
Wolof
Xhosa
Yiddish
Yoruba
Zhuang; Chuang
Zulu
Other
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Other Race
Patient Declined to Specify
White
Other
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
Other
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