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
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 How Did You Hear About Us?

Billing Information

Is The Billing Address the Same?
Title First Last MI Suffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Quaternary

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
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!

Reason for Visit: Secondary Reasons:

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? If yes, please describe:

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? If yes, please describe:

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Eye History

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: 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:

Family Eye History

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: STD's:

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

Race: Ethnicity: Preferred Language:

Submit Form

Acknowledgment of Privacy Policy and Practices

I understand that in an attempt to protect the privacy of my identifiable health information, Northfield Eye Care has established a Privacy Policy and guidelines for Privacy Practices within their office. This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purposes of diagnosis, treatment, payment and health operations. In accordance with HIPAA Regulations, a copy of the Northfield Eye Care Privacy Policy and Practices has been made available to me while in the office today. Should I choose to have a personal copy, one will be given to me at no charge.




Signature: Date:

Financial Agreement

I understand payment for services is due in full at the time services are rendered. I understand Northfield Eye Care will bill my insurance as a courtesy, but this is not a guarantee that my insurance will pay for services rendered or materials provided. It is my responsibility to know my insurance benefits and coverage. I am responsible for all co-pays, deductibles, and services or materials not covered my by insurance. In the event it becomes necessary for Northfield Eye Care to enlist the services of a collection agency and/or legal assistance, I will be responsible for any collection expenses and service charges. Should you have a credit within our office for longer than two years, a monthly maintenance fee of $10 will be assessed. If you notify us after services are rendered and materials ordered that you have vision insurance, we will supply you with a coded receipt that you can submit to receive reimbursement directly from your plan. However, be aware that your insurance company may only send you a partial reimbursement of the fees you paid. I have read, understand and agree to the above financial policy for payment of professional services and product fees.

I have read and understand the Financial Agreement at Northfield Eye Care.

Signature: Date:

Optomap

Northfield Eye Care is proud to present our patients with the latest in eyecare technology. We were the second eye care practice in the state of Tennessee to offer digital retinal scanning. We know you will be pleased with the results.



We highly recommend the Optomap exam because of these benefits:
  • Most patients can avoid having their pupils dilated with drops.
  • By declining, your exam may include dilation which may cause blurred vision and light sensitivity.
  • Fast, easy and comfortable.
  • A digital record of your retina that becomes part of your permanent file.
  • Enables us to educate you more fully about your eye health.
  • It enables us to better monitor your eye health annually.
  • Our commitment is to offer all our patients the highest standard of care available today.
Your insurance plan provides you with basic vision examination coverage, but does not include advanced disease detection procedures like the Optomap. The fee for this extended exam is only $45. If you have any questions or concerns, please don't hesitate to ask any of our staff or the doctors.




Signature: Date: