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:

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 Reasons: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
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:

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

Vision Vs. Medical Insurance Policy

Many of our patients have both vision and medical insurance, and we want you to understand the difference between the two. This is important because they differ in what they cover, pay, etc.

Vision coverage is designed to determine a prescription for glasses or contacts and is not equipped to deal with complex medical conditions and/or diseases. Therefore, the fee for this service is usually lower and does not include a detailed retinal exam.

When a medical condition or diagnosis is present (such as glaucoma, diabetes, dry eye or other eye diseases) it is necessary to file with your medical insurance. Any co-pays you have for a medical specialist will then apply. Some components of medical exams may not be covered by your insurance; therefore, you would be responsible for those fees. Medical fees are usually higher than vision fees. If you do not have medical insurance but require a medical exam, please realize your exam will be out of pocket.

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. The benefits quoted by your insurance company may change once the claim has been filed and is not guaranteed.

Our office does not make these rules; they are defined by insurance companies. Often we will not know which type of exam you require until we begin our testing.

By signing below you state that you understand the above and assign all benefits to us. Whether or not you have insurance, please understand that you are responsible for your charges. There will be no refunds for any professional services.

All fees, insurance co-pays, deductibles and contact lens evaluation fees (that insurance may not cover) are due at the completion of your exam.

Patient/Guardian Signature: Date:

Optomap

Important Information Regarding Your Upcoming Appointment


At Eyes on Westlake, we are dedicated to preserving your eye heath, improving your vision and maintaining your systemic health. We are following CDC guidelines while practicing social distancing in our office. We have modified our equipment and workflow to allow for an increase in social distancing.. Appointments have been scaled back significantly to create a safe and comfortable environment for your visit. Please be advised of the following guidelines and precautions that are now in effect:

  • 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.
  • If you are a new patient, please visit www.eyesonwestlake.com to fill out your patient history forms. Please submit your forms online and a copy of your medical/vision insurance cards to 817-674-7500 or hello@eyesonwestlake.com. If you have difficulties filling out your history online or have trouble locating your card, please call our office at 817-674-7500. Someone from our office will assist you in filling out or updating your medical and insurance history prior to your arrival.
  • We also 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.
  • We ask that all patients wear a mask. We will provide you with a 3-ply surgical mask if you do not have one. Please remember to sanitize or wash your hands upon entering the office. We will also be taking your temperature, and anyone above 100.4 degrees will be asked to reschedule their appointment.
  • 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

MEDICAL NECESSITY
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 stated below.

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.

DEDUCTIBLES
If my insurance determines that I have not met my deductible, I understand that I will be fully responsible for payment in a timely manner, no more than 30 days after I have been notified by insurance and/or provider. Yearly deductibles cannot be waived at any time by Eyes on Westlake.

PROFESSIONAL SERVICES AND MATERIALS
I understand that I am responsible for 100% of all professional fees rendered on the date of service. 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. If I do not pick up my materials within 60 days from my initial order, my materials will be returned to the laboratory, and my initial deposit will not be refunded. If I am to receive contact lenses by mail, I understand that I am required to pay in full at time of service.

Our Patient Satisfaction Guarantee applies to single vision and progressive lenses. We use only premium single vision optics and premium progressive addition lenses, otherwise known as no line bifocals. Less than one percent of our patients have difficulty adapting to our premium progressive lenses. We will remake a non-adapt progressive lens or single vision lenses one time, in the same frame. If it is still unsatisfactory, we will replace it with a lined bifocal or a single vision lens, in the same frame. While we make every attempt to solve these rare issues, no refunds will be given in a case where a patient does not adapt to a progressive lens or single vision lens.

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: