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:
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
Referred By:
Referring Doctor:
Are any family members seen by our office?:
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:
Insurance Information
Insurance Name:
None
AARP Health Care Options
Aetna
Aetna Medicare
Aetna Vision
American Pioneer Life Ins Co
Assurant Health
Blue Cross Blue Shield of Texas
Blue Cross Medicare Advantage
BMA
Boon-Chapman
Central United Life Insurance
Cigna
Cigna Healthy Rewards - Vision Network Svgs Program
Cigna International
Cigna Life Ins of Europe
Cigna PPO
Coeur
Conneticut General Life Ins.
Eye Care for Kids Foundation
EyeMed Vision Care
General Worldwide
Golden Rule Insurance Company
Group Health Incorporated
Humana
Humana/Medicare
Katy Lions Club
Manhattan Life
Marquette National Life
Medicare Part B - _
Meritain Health
MHealth
Mutual of Omaha
New Era
Nippon Life Insurance Co. of America
NO NAME
OptiCare Vision Plans
PHCS
Physician's Mutual
PPC
Principal Life Insurance Co.
RailRoad
Spectera
Superior Vision Services
TransAmerica Life Insurance Company
Tricare/Wisconsin Physicians Service
TRS-Care/Aetna
UHC/Medicare
UMR United Health Care Options PPO
United Health International
United Healthcare
United of Omaha Life Insurance Company
Unity Health Insurance
Vision Care Plan
Vision Service Plan
WEB-TPA
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!
Interested In Contact Lenses?
Yes
No
Ever Worn Contact Lenses?
Currently
Prior
Never
If yes, type of contacts worn in past:
Disposable
Conv. DW
Tinted
XW
Other
Do you have backup glasses?:
Yes
No
Other
Primary Vision Correction:
Conv XW-Full X
Disp. DW Full X
Glasses-Full Time
Glasses-Readers Only
None
RGP-DW
RGP-XW
Other
Do you want sunglasses?:
Yes
No
Do you want computer glasses?:
Yes
No
Do you have problems with glare?:
Yes
No
Interested in Laser Vision Correction?:
Yes
No
Do you currently have or have a history of the following conditions/symptoms?:
None
Itching
Burning, Stinging
Amblyopia
Eye Injuries
Eye Surgery
Flashes Of Light
Floaters
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Macular Degeneration
Other
Do you take any eye medications?:
None
Cromolyn NA 4%
Visine
Patanol
Xalatan
Travatan
alphagan P
Pred Forte
Antibiotic
Other
Last Eye Doctor:
Never
Don't Remember
Sorrenson
Wasser
Marez Slaughter
Other
Primary Care Physician:
Don't Have One
Don't Remember
Akin, Mark
Caven
David Martin
E.R. David
Enriquez
Fred Martin
Glaze
Gray, Lynne
Jeffrey Hallett
Jess Thompson
King
Kangos
Martinez
Merryman
None
Ream
Silverthorne
Stavinoha
Terry Sherman
Winn
Warren, Pamela
Other
Do you take any other medications?:
See ARRA
None
Allegra D
Birth Control
Claritin
Chlor-Trimeton
Inderal
Librax
Muscle Relax
Minipress
Premarin
Pamelor
Plaquenil
Reglan
Relafen
Sinequan
SLO-BID
Seldane
Synthroid
Seldane-D
Thyroxine
Verapamil
Zocor
Zoloft
Zantac
Other
Do you have any allergies?:
NKDA
See ARRA
None
Codeine
Penicillin
Sulfa Drugs
Environmental
Ocular
Seasonal
Other
Please describe any history of conditions such as asthma, diabetes, thyroid disease, etc.:
Family Med History:
Adopted
Diabetes Type 1
Diabetes Type 2
High Blood Pressure
Heart/Vascular Disease
Other
Family Eye History:
None
Cataracts
Glaucoma
Macular Degeneration
Retinal Disorders
Eye Turn
Other
Review of Systems
General:
None
Fatigue
Weight Loss
Cancer
Developmental Disability
Other
Ear/Nose/Throat:
None
Hearing Loss
Sinusitis
Dry Mouth
Laryngitis
Other
Skin:
None
Eczema
Rosacea
Psoriasis
Skin Cancers
Other
Cardiovascular:
None
Hypertension
Stroke
Heart Disease
Vascular Disease
Other
Respiratory:
None
Asthma
Bronchitis
Emphysema
COPD
Cigarette Smoker
Other
Musculoskeletal:
None
Osteoarthritis
Fibromyalgia
Muscular Dystrophy
Ankylosing Spondylitis
Joint Pain
Other
Psychiatric:
None
Anxiety
Depression
Insomnia
Other
Gastrointestinal:
None
Hernia
Ulcers
Crohn's Disease
Colitis
Other
Endocrine:
None
Diabetes Type 1
Diabetes Type 2
Thyroid Dysfunction
Hormonal Dysfunction
Other
Blood/Lymph:
None
Hypercholesterolemia
Anemia
Leukemia
Other
Neurological:
None
Multiple Sclerosis
Epilepsy
Cerebral Palsy
Tumor
Seizures
Other
Genitourinary:
None
Kidney Disease
Prostate Disease/Cancer
STD-Herpes/Chlamydia
Painful Urination
Frequent Urination
Yellow Jaundice
Other
Immune:
None
Drug Allergy
Rheumatoid Arthritis
Lupus
Environmental Allergies
Other
Eyes:
None
Glaucoma
Macular Degeneration
Cataract
Cataract Surgery
Patching/Amblyopia
Eye Turn
Inflammatory Disorders
Vision Correction Surgery
Other
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