Online Patient Form

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 Widowed	Employer / School Name
Misc/Guardian

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:

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 Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Other	Diabetes:	No Parents Siblings Grandparent Other
Thyroid Conditions:	No Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Other	High Cholesterol:	No Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Other
Heart Conditions:	No Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Other	Other:
Cancer:	No Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Other

Family Eye History

Does anyone in your family have any of these eye conditions?:

Macular Degen:	No Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Other	Glaucoma:	No Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Other
Retinal Detach:	No Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Other	Cataracts:	No Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Other
Lazy/Crossed Eye:	No Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Other	Blindness:	No Mother Father Sister Brother Grandmother Grandfather Aunt Uncle 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

Submit Form / Signatures

Contact Lens And Glasses Policy

We give a 90 day window after the initial contact lens fitting in which you are able to have your contacts adjusted at no charge. If you would like your contacts adjusted outside this time due to vision or comfort you will be recharged the initial contact lens fitting fee and the 90 day window will reset. Contact lens prescriptions once finalized are good for 1 year. If your irritation in contacts at a F/U is due to a medical issue it will be charged as an OV.

We give a 90 day window from the date a prescription was issued for adjustments to a glasses prescription. If you feel you have a prescription change outside 90 days but before 6 months from the initial time the prescription was issued we do charge a $50 refraction fee. If the change in vision is due to other issues such as allergies, corneal irritation, or diabetes that needs to be addressed there may be an office visit fee. If you would a like a prescription update 6 months or more after the initial prescription was given a new exam will required.

Please be aware that glasses are custom products. Once an order is placed we do not offer a refund but we can remake the lenses once if there is an adaptation issue.

I Understand And Acknowledge That I Have Read Accept The Contact Lens And Glasses Policy For Westlake Hills Vision Center.

Privacy Policy

**View Patient Privacy Policy**

I Have Understand And Ancknowledge That I Have Read The Privacy Policy For Westlake Hills Vision Center.

Sharing Of Personal Information

I authorize Westlake Hills Vision Center's medical staff to discuss my healthcare information (which may include history, diagnosis, test results, treatment and other health information) with the people listed below. This release authorization will remain in effect until terminated in writing by me.

My healthcare information by be released to the following people:
Name: Relationship: Contact Info
Name: Relationship: Contact Info

Do NOT release my personal healthcare information to anyone

Privacy: We will do our best to protect the privacy of your medical information. As per Federal Regulations, we have implemented a privacy policy and assigned a privacy officer. An overview of our Privacy Policy is available for you at our front desk. If you wish to see the entire policy, lease ask any staff member.

I DO I DO NOT allow you to leave a detailed message for me at my preferred method(s) of contact

Attestation
I authorize and request my insurance company to directly pay Westlake Hills Vision Center for any health benefits resulting from care I received from Westlake Hills Vision Center. I understand that my insurance company may not cover all services rendered on my behalf and I agree to assume responsibility for any services or materials not covered. I consent to the release to my insurance company of any medical records necessary to resolve claims for services rendered. I understand that co-pays and any services not covered by my insurance company are DUE IN FULL AT THE TIME OF SERVICE. I understand that the insurance that I wish to use for an exam must be presented at the time of the exam and cannot not be changed after. I understand that failure to provide complete and accurate information may result in denied or delayed insurance claims, an inaccurate diagnosis, or even inappropriate treatment. I certify that the information I have given is accurate and complete. I acknowledge that I been offered or received a copy of Westlake Hills Vision Center's Notice of Privacy Practices. I also authorize my insurance benefits to be paid directly to my provider, when such arrangements are made in advance. I understand that I am financially responsible for denied claims and non-covered services and/or materials. .

I Have Understand And Ancknowledge That I Have Read The Attestation Policy For Westlake Hills Vision Center.

Vision Vs Medical Insurance

Vision Insurance


Vision insurance covers an eye exam if you only have a prescription and want no other health conditions addressed. For instance if you are near-sighted (myopia), far-sighted (hypermetropia), have astigmatism or presbyopia (loss of near vision) and have not been diagnosed with any other conditions or would not like any other conditions addressed the exam would fall under vision insurance. If there is anything else that you would like discussed during the exam such as red eyes, dryness, allergies, or any drug prescription updates this would fall under medical and a separate visit may be needed. It would also fall under medical if you have been previously diagnosed with conditions such as cataracts, diabetes, glaucoma, macular degeneration etc. and would like them addressed.

Medical Insurance


Medical insurance will sometimes cover a routine exam where you have no health conditions but it is dependent on the medical insurance and your individual coverage. If you have ever been diagnosed with health conditions such as diabetes, macular degeneration, glaucoma, choroidal nevus (a freckle in the back of the eye) and would like them addressed the exam would fall under medical insurance and may be covered under your optometry benefit. If your medical insurance does not cover a routine exam the refraction portion of the exam is not covered. The refraction portion of the exam is the part where we determine your prescription. This part would be out of pocket. This is often the case with Medicare if you do not also have vision insurance. With some insurances if you have both medical and vision we can coordinate benefits so the vision insurance will pay for the refraction and the medical will pay for the exam. However, this is not possible for every insurance. For instance, this is not possible if the vision insurance is Eyemed.

I understand that my exam will be filed based on the above guidelines. Those guidelines are dictated by your insurance.

I Understand And Ancknowledge That I Have Read The Vision Vs. Medical Insurance Policy For Westlake Hills Vision Center.

Westlake Hills Vision Center Frame Waiver

We will happily adjust and maintenance a frame not purchased from Westlake Hills Vision Center. Every effort will be made to use the utmost care while handling your frame. However, we cannot be held liable for any damage that may occur when inserting new lenses into or adjusting any frame that is not purchased or currently warrantied through Westlake Hills Vision Center. Adjusting includes any service that requires frame handling such as inserting nose pads or screws. All frames purchased through Westlake Hills Vision Center carry a 1 year warranty.

Although rare, if you choose to use a your own frame but have new lenses inserted, should breakage occur when lenses are being inserted at the lab, Westlake Hills Vision Center will not be financially liable but will offer a 30% discount on any other frame a patient wishes to use for lens insertion.

Signature: Date: