Online Patient Form

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Patient Information


Title First Last MI Suffix Nickname Pronoun
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Birth Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information



Medical

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary

Vision

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary

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?: If other, please list here:
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 / Patient Signatures



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

Notice of Privacy Practices

Please read the "Notice of Privacy Practices" and sign below. I acknowledge that I have reviewed OptomEyes Vision's Notice of Privacy Practices.

View Notice of Privacy Practices Form

Patient Signature: Date:

Assignment and Release

I certify that I, and / or my dependent(s), and assign directly to OptomEyes Vision all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed

Patient Signature: Date:

Standard Dilated Fundus Exam

We are committed to maintaining the highest level of care for the early detection and prevention of eye disease. As a result , the dilated fundus exam is included as part of the comprehensive eye exam. When the pupils are dilated with drops, we can obtain a better view of the back of the eyes to detect early signs of ocular pathologies. Side effects may include blurred near and / or distance vision and light sensitivity for 4-6 hours. 'Some patients may experience adverse or allergic reactions to the dilation drops.

IF YOU ARE DECLINING THE DILATED FUNDUS EXAM, READ & SIGN BELOW
I do not wish to have my eyes dilated at this time. I understand the benefits of this procedure in the early detection and diagnosis of ocular disease.

Patient Signature: Date:

Additional Examination

Fundus Photo Retinal Exam
The Fundus Photo Retinal Exam is a retinal scan that provides the doctor with an image of the retina to detect presence of eye disease.

The fee for the Fundus Photo Retinal Exam is an additional $39 and is not covered by insurance.
I want the fundus photo taken. Yes No

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