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:		Alerts:
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

Billing Information

Is The Billing Address The Same? 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 Insurance

Insurance Information

Insurance Name:	None AARP Health Care Options AARP Medicare Supplement/ Fixed Indemnity by UHC Advantica Aetna Aetna Discount Aetna Global Benefits Aetna Medicare Always Vision AlwaysCare American Heritage Life Insurance Company Assurant Health Avesis Bankers Fidelity Benefit Management Administrators, Inc. Block Vision Blue Cross Blue Shield Blue Cross Blue Shield-Anthem Blue Cross Blue Shield of Arizona Blue Cross Blue Shield of Florida Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Louisiana Blue Cross Blue Shield of Texas Blue View Vision Boon-Chapman Christian Fidelity Cigna Cole Vision Services Colonial Penn Life Insurance Company D H Evans & Assoc. Davis Vision Davis Vision Insurance Ella Eyes Membership Envolve Europeiske Eyecare Plan of America Eyemed Vision Care First Health Network GMC International Administration Health First Health Spring Heritage Vision Plans HMA Humana Humana-Medicare Humana Choice Care Humana Guidance Humana Vision Humana Vision Care Plan Mail Handlers Benefit Medicare Medicare of Texas Medico Insurance Company Meritain Health MESVISION MetLife Vision MSLA Veteran Mutual Assurance Administrators Nationwide Insurance Nationwide Vision Insurance NVA Omaha Supplemental Insaurance Company Opticare Opticare OptumHealth PHCS PHCS-Health Plans Prime Health Services Principal Financial Group Principal Life Ins. Co. Prompt Pay Regence Blue Shield Safeguard Sch G Discount Share Plan Spectera Superior Vision Services, Inc. Texan Plus Eyemed Vision Insurance Texan Plus Medical Texas Health Spring The Mail Handlers Benifit Plan Tricare Tricare West Region TRPN- Three Rivers Providers Network Trusted Plans Service Corp UniCare Uniform Medical United Healthcare United Healthcare United Healthcare AARP Medicare United Healthcare UMR United of Omaha Life Insurance Company Universal Fidelty Life Insurance Company USA Managed Care (USA MCO) VBA - Vision Benefits of America VCA Versant Health VSP
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:

Secondary Insurance

Insurance Information

Insurance Name:	None AARP Health Care Options AARP Medicare Supplement/ Fixed Indemnity by UHC Advantica Aetna Aetna Discount Aetna Global Benefits Aetna Medicare Always Vision AlwaysCare American Heritage Life Insurance Company Assurant Health Avesis Bankers Fidelity Benefit Management Administrators, Inc. Block Vision Blue Cross Blue Shield Blue Cross Blue Shield-Anthem Blue Cross Blue Shield of Arizona Blue Cross Blue Shield of Florida Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Louisiana Blue Cross Blue Shield of Texas Blue View Vision Boon-Chapman Christian Fidelity Cigna Cole Vision Services Colonial Penn Life Insurance Company D H Evans & Assoc. Davis Vision Davis Vision Insurance Ella Eyes Membership Envolve Europeiske Eyecare Plan of America Eyemed Vision Care First Health Network GMC International Administration Health First Health Spring Heritage Vision Plans HMA Humana Humana-Medicare Humana Choice Care Humana Guidance Humana Vision Humana Vision Care Plan Mail Handlers Benefit Medicare Medicare of Texas Medico Insurance Company Meritain Health MESVISION MetLife Vision MSLA Veteran Mutual Assurance Administrators Nationwide Insurance Nationwide Vision Insurance NVA Omaha Supplemental Insaurance Company Opticare Opticare OptumHealth PHCS PHCS-Health Plans Prime Health Services Principal Financial Group Principal Life Ins. Co. Prompt Pay Regence Blue Shield Safeguard Sch G Discount Share Plan Spectera Superior Vision Services, Inc. Texan Plus Eyemed Vision Insurance Texan Plus Medical Texas Health Spring The Mail Handlers Benifit Plan Tricare Tricare West Region TRPN- Three Rivers Providers Network Trusted Plans Service Corp UniCare Uniform Medical United Healthcare United Healthcare United Healthcare AARP Medicare United Healthcare UMR United of Omaha Life Insurance Company Universal Fidelty Life Insurance Company USA Managed Care (USA MCO) VBA - Vision Benefits of America VCA Versant Health VSP
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:

Tertiary Insurance

Insurance Information

Insurance Name:	None AARP Health Care Options AARP Medicare Supplement/ Fixed Indemnity by UHC Advantica Aetna Aetna Discount Aetna Global Benefits Aetna Medicare Always Vision AlwaysCare American Heritage Life Insurance Company Assurant Health Avesis Bankers Fidelity Benefit Management Administrators, Inc. Block Vision Blue Cross Blue Shield Blue Cross Blue Shield-Anthem Blue Cross Blue Shield of Arizona Blue Cross Blue Shield of Florida Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Louisiana Blue Cross Blue Shield of Texas Blue View Vision Boon-Chapman Christian Fidelity Cigna Cole Vision Services Colonial Penn Life Insurance Company D H Evans & Assoc. Davis Vision Davis Vision Insurance Ella Eyes Membership Envolve Europeiske Eyecare Plan of America Eyemed Vision Care First Health Network GMC International Administration Health First Health Spring Heritage Vision Plans HMA Humana Humana-Medicare Humana Choice Care Humana Guidance Humana Vision Humana Vision Care Plan Mail Handlers Benefit Medicare Medicare of Texas Medico Insurance Company Meritain Health MESVISION MetLife Vision MSLA Veteran Mutual Assurance Administrators Nationwide Insurance Nationwide Vision Insurance NVA Omaha Supplemental Insaurance Company Opticare Opticare OptumHealth PHCS PHCS-Health Plans Prime Health Services Principal Financial Group Principal Life Ins. Co. Prompt Pay Regence Blue Shield Safeguard Sch G Discount Share Plan Spectera Superior Vision Services, Inc. Texan Plus Eyemed Vision Insurance Texan Plus Medical Texas Health Spring The Mail Handlers Benifit Plan Tricare Tricare West Region TRPN- Three Rivers Providers Network Trusted Plans Service Corp UniCare Uniform Medical United Healthcare United Healthcare United Healthcare AARP Medicare United Healthcare UMR United of Omaha Life Insurance Company Universal Fidelty Life Insurance Company USA Managed Care (USA MCO) VBA - Vision Benefits of America VCA Versant Health VSP
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:

Primary Reasons:	Secondary Reasons:

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

Submit Form / Patient Signatures

HIPPA: Acknowledgment of Receipt of Privacy Notice

By signing this acknowledgment of Receipt of Notice of Privacy Practices (the "Notice"); I acknowledge and agree that I have received a copy and/or read a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below.

I understand that the office may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit the office to perform its administrative duties, provide me with eye care services and products, process my vision/medical benefit claims and communicate with me regarding vision/medical claims and communicate with me regarding vision/medical care services provided by the office (for example, mailings of exam reminders or information for services/products provided by the office).

I can be assured that this office does not sell my personal health information of any kind to a third party for such party's own use. I authorize the office to submit my vision/medical benefit claims to my plan sponsor or health plan to receive reimbursement directly for the vision/medical services/products that I have received from the office.

INSURANCE SIGNATURE ON FILE

I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits, and I authorize payment of these benefits directly to the doctor on my behalf for any services and materials furnished. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage, my signature authorizes release of the above medical information to the insurer or agency shown, and authorizes my doctor to act as my agent, as above. I understand I am responsible for the balance of fees not paid by my insurance.

REFRACTION POLICY: * FOR INSURED PATIENTS ONLY *

The Centers for Medicare and some insurance companies consider a refraction to be a NON-COVERED service. Please be aware it is the responsibility of the patient to pay for the refraction unless otherwise stipulated by your insurance carrier. Our office currently charges $95.00 for this procedure, but provides a prompt pay price of $45.00 to the patient when paid at the time of service. The refraction fee is paid in addition to the eye exam co-pay. I have read the above information and understand I may be charged a prompt pay price of $45.00 at the time of service unless otherwise stipulated by my insurance company.

Electronic Communication

Please be advised that any communications we received from you, the patient, through electronic means, such as text or email, will be unsecured. Our office will not send any health or medical records to you through these channels, unless requested by you. Our office will always strive to protect your records through proper means.

By signing this, you fully have understood and accepted all the risks involved in an open channel communication.

By entering my name below, I agree to all of the above and I accept this as my digital signature

Patient Lifetime Signature or Patient's Legal Representative Date: Copy Signature and date to all boxes below

Dilated Fundus Exam:

Dilation provides a more comprehensive internal ocular health analysis of the eye. The side effects include temporary blurry vision at near, some blur at distance and light sensitivity. This procedure is included with your comprehensive exam. There is a $25 FEE charge charge if patient have this procedure after 30 from the time of exam.

Yes. I want the Dilated Fundus Exam I will ask the Doctor

Optomap Retinal Exam:

An effective computerized imaging that scans 80% of your retina to help your Doctor evaluate, monitor, and treat various eye conditions. Our staff will scan your eye at the time of your exam, and your doctor will ask to review the images. If you agree to the viewing, there is a $45 FEE for the Doctor to review the images with you.

Yes. I want the Dr. to review the Optomap I will ask the Doctor

Visual Field Analyzer:

A visual field screening can assist us in early detection of glaucoma, retinal problems, and some neurological diseases and may diagnose causes of headaches. There is a $25.00 fee for the visual field screening.

Yes. I want the Visual Field Analyzer I will ask the Doctor

I understand that without these tests, certain eye diseases and conditions may not be discovered. I agree to assume all risk associated with refusing these tests, indemnify, hold harmless, and release Ella Eyes, its employees and optometrists, from any and all claims or liability whatsoever related to failure to diagnose and/or treat any eye conditions due to lack of diagnostic information which could have been obtained by these tests.

Refund/Remake Policies

1. We will make your lenses according to your Doctor's written prescription. Our goal is to provide the highest quality products and the best possible service.
2. We CANNOT CANCEL your order or REFUND your lenses after your lenses has been ORDERED/ PROCESSED including partial deposits.
3. Patient understands that frame choice is FINAL once the lenses have been processed
4. Patients experiencing adaptation issues to any prescription MUST return within 30 days from the date of purchase for a 1 time remake.
5. No Refunds will be given to patients that do not adapt to their prescriptions. We offer to REMAKE the lenses within the 30 days from the date of your order.
6. Ella Eyes standard policies include 30 days of customer satisfaction in which we will gladly adjust, repair, or equally exchange your new glasses if there are any defects.
7. We offer a one time, within the year of purchase, a SCRATCHED lenses warranty of the same RX REMAKE at no charge.
8. We offer to replace your BROKEN OR DAMAGED glasses 1 time with the same or equivalent product at a 50% off retail pricing up to 1 year from the date of your purchase. We do not cover lost or stolen glasses.

**Patient acknowledges receipt of Ella Eyes @ Woodway Collection "Remake & Refund Policies" and fully understands the policies.**





All PROFESSIONAL SERVICES ARE DUE AT TIME OF SERVICE AND ARE NON-REFUNDABLE
**There is no fee for follow up visits on glasses or contact lens fitting within 30 days from initial exam. Any follow ups on glasses or contact lens past 30 days will be charged an office visit fee.



By entering my name below, I agree to all of the above and I accept this as my digital signature:

Patient Signature or Patient's Legal Representative Date

Contact Lens Service Agreement

Contact lens wear is a type of correction that requires commitment and good hygiene. Not everyone can wear contact lenses successfully. There are many factors that can influence the success of your fit such as allergies, oily tears, dry eyes, medications, improper care or failure to return for follow-up visits. It is not always possible to determine in advance whether you will be those who will successfully enjoy contact lens wear. Even with the best fit, contact lens vision, in some cases, may not be as clear and comfortable as spectacle wear.

Eye Infections can occur even with proper contact lens usage and care. Contact lenses can also cause red eyes, blurred vision, light sensitivity, itchiness, mucus build-up, and can become uncomfortable. Lenses should not be worn if these conditions occur. If these conditions occur, an OFFICE VISIT should be made immediately.

Follow-up visits are extremely important. It is the patient's responsibility to return to the doctor when the contact lenses are dispensed and for routine follow-up visits per the doctor's instructions. It is also necessary for the patient to return for a routine eye exam every 12 months or sooner as all spectacle/contact lens prescriptions will expire one year from the date of the initial exam unless specified by the doctor.

The contact lens exam includes an eye exam, contact lens fitting, and (3) follow-up visits for one month per doctor's instructions, from the initial date of the exam. If the patient does not return for the scheduled visits within the allowed time, then there will be a fee accrued for visits after the month is up.

All fees charged for the EXAMINATION, FITTING, and SERVICE AGREEMENT (conventional, disposable, and planned replacement) are NON-REFUNDABLE.

I HAVE READ, UNDERSTOOD, AGREED to the ABOVE CONTACT LENS AGREEMENT

Contact Lens Digital Consent

I authorized my eye doctor to provide me with a digital copy of my contact lens prescription by,

Patient Portal (Most Secure) Email Text

at the end of my contact lens fitting.

Patient Signature or Patient's Legal Representative Date