Online Patient Form

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After completing all the forms, please submit your data on the final tab.
New Patients: Please enter your Name, Address, Cell phone number, Birthday, Sex, and Email address. Complete Medical History and Patient Signature Forms.
Existing patients: Please enter your Name, Cell phone numbers, Email Address, and skip to Medical History and Patient Signature forms. Thank you!

Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
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/GuardianDrivers License #



Medical History


Chief Complaint


Exam Type


Past Ocular Complaints
Ocular Surgery
Last Exam Date Primary Vision Correction

Medications, Allergies, Other History

Prescription Medication - No current medications Allergies - No known drug allergies
OTC Medication

Social History

Smoking Status Discussed Cessation
Alcohol Recreational Drug use
Occupation Digital screen use

Patient Medical History

Cancer Cardiovascular
Hypertension High Cholesterol
Thyroid Pregnant Or Nursing
Other
Diabetes YrDx
HBA1C Taken
Primary Care Physician
Last Physical
Endocrinologist/specialist

Review Of Systems

General Ear, nose and throat
Cardiovascular Respiratory
Genital, kidney and bladder Muscles, bones and joints
Gastrointestinal Skin
Neurological Psychiatric
Endocrine Blood/lymph
Allergic/immunologic Injuries/Surgeries

Family Medical History

Cancer Diabetes
Cardiovascular Hypertension
High Cholesterol Thyroid
Amblyopia/Strabismus Blindness
Cataracts Glaucoma
Macular Degeneration Retinal Detach
Other


Submit Form / Patient Signatures



PLEASE READ THIS ELECTRONIC SIGNATURE CONSENT BEFORE YOU PROCEED. Your electronic signature shall have the same force and effect as an original signature and shall be deemed (i) to be "written" or "in writing" or an “electronic record” (ii) to have been signed and (iii) to constitute a record established and maintained in the ordinary course of business and an original written record when printed from electronic files. Such paper copies or "printouts," if introduced as evidence in any judicial, arbitral, mediation or administrative proceeding, will be admissible as between the parties to the same extent and under the same conditions as other original business records created and maintained in documentary form.

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Retinal Examination, Examination and Billing Protocols, Optical Policies - Richmond location only, Patient Owned Frames - Richmond location only, Notice of Privacy Practices, Authorization and Consent

View Retinal Examination, Examination and Billing Protocols, Optical Policies, Patient Owned Frames, Notice of Privacy Practices, Authorization and Consent

Please select one of these two options:

I would like Optomap retinal imaging. I agree to the $39.00 fee for service. I understand that this new technology is not covered by my insurance. Reduced to $29.00 for returning patients.

I prefer dilation with eye drops. I understand that my near vision will be blurry, and my eyes may be light sensitive for up to 6 hours. I understand that I am not supposed to drive more than 3 miles, or operate any machinery until I feel like my vision has suitably recovered.

ELECTRONIC SIGNATURE (Guardian if under 18 years of age):
Date:

Examination and Billing Protocols, Optical Policies, Patient Owned Frames, Notice of Privacy Practices, Authorization and Consent Signature

ELECTRONIC SIGNATURE (Guardian if under 18 years of age):
Date: