Online Patient Form

Click here to return to the previous website.

After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information


TitleFirstLastMISuffixNickname
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 Favorite Candy:
Current favorite artist/jam:

Billing Information

Is The Billing Address The Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Primary Vision

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:

Primary Medical

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 Vision

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 Medical

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!

Eye History

Reason for Visit:
Primary Reason For Visit: Please list any other eye concerns/issues:

Please list any eye condition/disease that you've been diagnosed with along with any eye surgeries and the date:
Please list any eye medications or eye drops you are currently taking:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses?

Interested In Glasses?
Interested In Contact Lens?
Interested In Laser Vision Correction?

Medical History

Medications:
Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing:


Family Eye History

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

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Blindness:
Keratoconus:

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:

Submit Form / Patient Signatures

Optomap

Important Information Regarding Your Upcoming Appointment


Dear Valued Patient,

At Eyes on Westlake, we are dedicated to preserving your eye heath, improving your vision and maintaining your systemic health. Please call us 48 hours in advance if you are unable to make your appointment or if you are unable to follow the requirements below.

  • We require that all patients receive the Optomap digital retinal imaging examination for $39. We have heavily invested in state-of-the-art technology to maximize your experience and expedite your visit. Over 85% of patients have electively chosen this method of retinal examination in the past; it will now be mandated as we believe this is the best way to evaluate your ocular health and it is considered standard of care at our practice. Dilation protocol requires several drops, physical contact with the face for extended periods, a close working distance, and adds an additional 30 minutes to your examination. Dilation will also cause blurry vision at near for 4-6 hours and light sensitivity. We will utilize the Optomap retinal exam to minimize personal contact while providing you with the best possible care and technology. Our Optomap imaging system is able to capture a high definition image of your retina to detect sight threatening and systemic disease such as diabetes, high blood pressure and even cancer in a fraction of a second. This will improve your safety by decreasing the amount of time you spend in the office, as well as the amount of time you spend with any one person. You will be able to view your own retinal images and this will serve as a permanent record to track and compare over time. If you cannot afford the $39, please inform our staff prior to your appointment by email.

  • If you have any of the following symptoms: fever, cough, chills, shortness of breath, muscle pain, sore throat, significant loss of smell or taste, if you have been diagnosed or exposed to anyone with known COVID-19 in the last two weeks or have traveled internationally in the past two weeks, please reschedule your appointment.


    • Thank you in advance for your understanding. We want to continue to provide the best in eye care while keeping everyone safe. Be safe and be well,

    Eyes on Westlake team

    Patient/Guardian Signature: Date:

    NOTICE OF PATIENT PRIVACY RIGHTS, PROTECTION, AND RESPONSIBILITIES

    COPAY's
    I understand that I am responsible to pay all co-payments at the time of service, prior to leaving. Co-payments cannot be waived at any time by Eyes on Westlake.

    INSURANCE
    It is important for you to accurately provide your vision and medical insurance information at least 24 hours prior to your examination, including any change in information, as we will not be able to file any claims with your insurance at a later date. Missed appointments without a courtesy 24-hour notice will incur a charge of $45.00. The benefits quoted by your insurance company may change once the claim has been filed and are not guaranteed. If you do not have medical insurance but require a medical exam, please realize your exam will be out of pocket. If my insurance determines that a medical service and/or material are not covered, I acknowledge that I have been notified and will assume full responsibility for the service(s) and/or material in a timely manner, no more than 30 days after I have been notified. By signing below you state that you understand the above and assign all benefits to us.

    PROFESSIONAL SERVICES AND MATERIALS
    I understand that I am responsible for 100% of all professional fees rendered on the date of service. There will be no refunds for any professional services. If I am supplying my own frame, I understand that many plastic and metal products may weaken over time and I will not hold Eyes on Westlake or my insurance carrier responsible for accidental laboratory breakage. All fees, insurance co-pays, deductibles and contact lens evaluation fees (that insurance may not cover) are due at the completion of your exam.

    REFUNDS, REMAKES & WARRANTIES
    Our office sells custom-made products and therefore cannot issue a full refund for glasses once they have been ordered. Cancellations will be subject to a restocking fee if the job has been started at the lab.We offer a one-time, 60-day period remake policy. This includes adding or removing lens options, non-adapts to certain lens designs or materials, frame changes, or changes in your prescription. Refunds will not be given on any material or lens design changes. Any additional remakes will be subject to fees.We believe in using premium, high quality products and extend the manufacturer warranty to the patient. All lenses include a 2-year scratch warranty.

    HIPAA
    I understand that under the Health Insurance Probability ACT of 1996 (HIPAA), which I have been provided a copy upon request, that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician certifications.

    AGREEMENT


    Patient Signature/Guardian: Date:

    Please list the name of any individuals we are able to share or discuss your medical information with below: