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:
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		Pharmacy

Billing Information

Is The Billing Address 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:

Primary Medical

Insurance Information

Insurance Name:	None AARP Advantra Aetna Aetna (FIRST HEALTH) All Savers (UHC) ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC American Postal Workers Union (APWU) Assurant Health (PHCS) Avesis Baylor Scott & White BCBS - Blue Cross Blue Shield (Out of State) BCBS - Blue Cross of Idaho BCBS TX- Blue Cross and Blue Shield of Texas BCBS TX- Medicare Advantage Plan Boon- Chapman Care N Care Christian Brothers Services Cigna Cigna Global Health Coast to Coast CoreSource Coventry Health Care of Kansas, Inc. - Kansas City EyeMed First Health Network First Health Network - Liberty Health Golden Rule Insurance Company Great West Healthcare Group and Pension Administrators HealthSmart Benefit Solutions, Inc Humana HumanaVision (9798307) Medicare - Railroad Medicare Secondary Medicare TX MedicareComplete - Aetna MedicareComplete - Humana MedicareComplete - UHC AARP MedicareComplete - UHC PO Box 163195 MedicareComplete - UHC PO Box 30975 Mega Life And Health Insurance Meritain Health Mutual Of Omaha Nippon Life Insurance Co of America PacifiCare of Texas PHCS Principal Life Financial Private Pay Sterling Option 1 Superior Vision Texas True Choice TML Multistate IEBP Tower Life Insurance Co. TRICARE West Region Trustmark Health Benefits (Aetna) Trustmark Insurance Company UMR Union Pacific Rail Road United American Insurance United Healthcare Global UnitedHealthcare of Texas VSP WebTPA (Aetna) WellMed (UHC)
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Primary Vision

Insurance Information

Insurance Name:	None AARP Advantra Aetna Aetna (FIRST HEALTH) All Savers (UHC) ALLEGIANCE BENEFIT PLAN MANAGEMENT,INC American Postal Workers Union (APWU) Assurant Health (PHCS) Avesis Baylor Scott & White BCBS - Blue Cross Blue Shield (Out of State) BCBS - Blue Cross of Idaho BCBS TX- Blue Cross and Blue Shield of Texas BCBS TX- Medicare Advantage Plan Boon- Chapman Care N Care Christian Brothers Services Cigna Cigna Global Health Coast to Coast CoreSource Coventry Health Care of Kansas, Inc. - Kansas City EyeMed First Health Network First Health Network - Liberty Health Golden Rule Insurance Company Great West Healthcare Group and Pension Administrators HealthSmart Benefit Solutions, Inc Humana HumanaVision (9798307) Medicare - Railroad Medicare Secondary Medicare TX MedicareComplete - Aetna MedicareComplete - Humana MedicareComplete - UHC AARP MedicareComplete - UHC PO Box 163195 MedicareComplete - UHC PO Box 30975 Mega Life And Health Insurance Meritain Health Mutual Of Omaha Nippon Life Insurance Co of America PacifiCare of Texas PHCS Principal Life Financial Private Pay Sterling Option 1 Superior Vision Texas True Choice TML Multistate IEBP Tower Life Insurance Co. TRICARE West Region Trustmark Health Benefits (Aetna) Trustmark Insurance Company UMR Union Pacific Rail Road United American Insurance United Healthcare Global UnitedHealthcare of Texas VSP WebTPA (Aetna) WellMed (UHC)
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
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!

Eye History

Reason for Visit:

Comprehensive Eye Exam Contact Lens Follow Up Medical Visit (Red Eyes, Eye injury, etc.) Other

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 Parents Siblings Grandparent Other	Diabetes:	No Parents Siblings Grandparent Other
Thyroid Conditions:	No Parents Siblings Grandparent Other	High Cholesterol:	No Parents Siblings Grandparent Other
Heart Conditions:	No Parents Siblings Grandparent Other	Other:
Cancer:	No Parents Siblings Grandparent Other

Family Eye History

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

Macular Degen:	No Parents Siblings Grandparent Other	Glaucoma:	No Parents Sibling Grandparent Other
Retinal Detach:	No Parents Siblings Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other
Lazy/Crossed Eye:	No Parents Siblings Grandparent Other	Blindness:	No Parents Siblings Grandparent 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

Eye Wellness Screenings

Advanced Eye Wellness Screenings:

These 3 screenings go beyond your regular eye exam for optimal preventative care to help detect and evaluate any possible conditions including, but not limited to, diabetic retinopathy, retinal detachment, macular degeneration, and more.

Retinal Imaging (Optos):      $43

• Ultra-wide field imaging technology used to evaluate the health of your retina
• Fast, easy, and comfortable for all ages; and digital images are stored electronically for yearly comparison
• Diagnose and monitor ocular pathology such as - retinal detachments, floaters, holes, tears and vascular anomalies (due to diabetes, hypertension, high cholesterol, etc)

Macula Scan (OCT):      $35

• High resolution, cross sectional and 3D ultrasound like images of the retina
• Analyzes macular health (holes, swelling, degeneration, ARMD)
• Detects unexplained decrease in your vision due to certain medications

Visual Field (VF):      $22

• Can detect dysfunction in field of vision, possibly caused by medical conditions such as headaches, glaucoma, stroke, brain tumors or other neurological deficits
• Helps detect and monitor the stages of glaucoma

Save $21 when you sign up for all three Advanced Screenings!

I would like these Advanced Wellness Screenings (Please initial):

OPTOS OCT VF

Eye dilation widens the pupils using a medicated eye drop. Side effects may include light sensitivity, blurry vision, and headaches. We do not recommend dilation if you are pregnant or have other concerning conditions. Please initial below for your choice.

I would like my eyes dilated today
I would not like my eyes dilated and would not like to have any AdvancedScreenings

Office Policies

The Plano Eye Care Center General Office Policy:

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

View Office Policy Form

Patient Name (Please print full name): Date:
Signature of person financially responsible:
(If under 18 year's old, parent or guardian signs)

PLEASE TURN OFF YOUR CELL PHONE AND REFRAIN FROM USING IT DURING YOUR VISIT. PLEASE DO NOT EAT FOOD OR BRING ANY BEVERAGE INTO EXAM ROOM AREAS.

CONSENT TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

The Notice of Privacy Practices

The Plano Eye Care Center is required to provide to you a notice that describes how information about you may be used and disclosed. Additionally, we must provide you information on how you may get access to this information. These policies and practices are defined in the “Notice of Privacy and Policies and Practices” displayed in our office. PLEASE REVIEW IT.

How we may use and disclose your health information
Your health information will be used at The Plano Eye Care Center for the purpose of treatment, obtaining payment, or supporting the day-to- day health care operations of the practice.

Restrictions on the use or disclosure of your health information
You may request a restriction on the use of disclosure of your protected health information. However, The Plano Eye Care Center may or may not agree to your request. Please consult with a practice representative or Office Manager for additional information or clarification.

Changes to Privacy Practices
The Plano Eye Care Center reserves the right to change or modify the privacy practices outlined in the Notice of Privacy Practices Brochure. We will notify you of any changes made either by mail, at your next appointment, or any other pre-approved method that you request.

I have read this consent form, and reviewed the "Notice of Privacy Practices" and give my permission to The Plano Eye Care Center to use and disclose my health information in accordance with this consent and the notice provided.

Name Of Patient: Signature Of Patient / Date:
Patient Representative: Signature Of Representative / Date:
Relationship To Patient:

AUTHORIZATION OF USE/DISCLOSURE OF PROTECTED INFORMATION

Persons Authorized to Receive Personal Health Information:

Name of Person / Phone Number: Name of Person / Phone Number:
Signature of Patient / Date:
Patient Representative Signature/ Relationship to Patient:

** By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I accept has the same validity and meaning as my handwritten signature.

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