Online Patient Form

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Patient Information


TitleFirstLastMISuffixNickname
Address:
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
Misc/Guardian

Billing Information

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TitleFirstLastMISuffix
Address:
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:
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

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.

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