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
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name

Billing Information

Is The Billing Address the Different?
Title First Last MI Suffix
City: State: 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 (Please Update This Section):
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:

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:

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:

Social History


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

Race: Ethnicity: Preferred Language:

Submit Form / Signatures

Contact Lens And Glasses Policy

We will happily adjust a contact lens prescription at no charge as long as it falls within 90 days after the initial contact lens fitting. 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 follow up is due to a medical issue it will be charged as an Office Visit.

We have a 60 day love your glasses guarantee policy. If in the first 60 days you are unhappy with the frame or prescription, we will happily remake the lenses for you. If the prescription is an outside prescription, we just ask that you have the original prescribing office adjust the 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 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 have understood and acknowledge 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, please 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

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.

Insurance Info


We accept VSP. VSP is a vision insurance and can be used when no other eye issues or conditions are present. 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. We are qualified to and will happily treat any eye conditions, however, we do not accept any medical insurances. For those that qualify to use vision insurance, we will happily file to VSP for patients if they have insurance but that is the only vision insurance we accept. We can provide paperwork, if you would like so you are able to file if you do not have VSP and the visit will be at our private pay rates.

I understand and acknowledge that I have read the Insurance Info 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. Although rare, if you choose to use 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(new date required each year):

Photo Permission

I DO or DO NOT give Westlake Hills Vision Center Permission to use any photo taken in the office of myself in glasses on social media.

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