Online Patient Form
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Demographics
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State/ZipCode
TX
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
UT
VT
VI
VA
WA
WV
WI
WY
Cell Phone:
Home Phone:
Other Phone:
Alerts:
Work 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
Polygamous
Widowed
Employer / School Name
Primary Doctor
No Doctor Assigned
Dr. Guagenti Engler, O.D., Lori
Dr. Hackley, James
Dr. Sims, O.D., Stephanie
Misc/Guardian
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other Race
Patient Declined to Specify
Other
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
Other
Please list all the individuals authorized for us to discuss your health information:
Spouse:
Parent:
Step-Parent:
Other Person:
May we leave a message on:
Your answering machine/voicemail at home:
Yes
No
Your voicemail at work:
Yes
No
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address
City
State
ZipCode
TX
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
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Medical Insurance
Insurance Information
Insurance Name:
None
New Insurance
New Insurance
New Insurance
AARP
Advantica
Aetna
Aetna Vision Network
Anthem
Aultcare
Avesis
Banker's Life and Casualty
Block Vision
Blue Cross Blue Shield
Cigna
Cigna Vision
Coresource
Davis Vision
Davis Vision Discount Plan
DMC
EyeMed
EyeMed Discount Plan
Golden Rule Insurance Co
Health Span
HealthCare Solutions Group
HealthPartners
Highmark Blue Cross Blue Shield Vision Claims
Humana
Humana Vision Care
InfantSEE
InHealth Ohio PPO Connect
Medicaid
Medical Mutual of Ohio
Medicare
MediGold
Meritain Health
MHBP
Multiplan
Mutual of Omaha
New Insurance
New Insurance
NGS, Inc. DMEPOS Operations, Medicare DMEPOS Claims
Ohio State Prime Care Advantage/NGS CoreSource
Optima Health
OptumHealth
PHCS
Physicians Mutual
PPO Connect
Railroad Medicare Part B Office
Revision
Spectera
Spectera Discount Plan
Standard Life and Accident Insurance Company
Starmark
Superior Vision
SuperMed Network
TLC
Tricare
UMR
United Healthcare
UPMC Health Plan
USA Senior Care
USAA
VSP
VSP Access Plan
Worker's Comp
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:
Vision Insurance
Insurance Information
Insurance Name:
None
New Insurance
New Insurance
New Insurance
AARP
Advantica
Aetna
Aetna Vision Network
Anthem
Aultcare
Avesis
Banker's Life and Casualty
Block Vision
Blue Cross Blue Shield
Cigna
Cigna Vision
Coresource
Davis Vision
Davis Vision Discount Plan
DMC
EyeMed
EyeMed Discount Plan
Golden Rule Insurance Co
Health Span
HealthCare Solutions Group
HealthPartners
Highmark Blue Cross Blue Shield Vision Claims
Humana
Humana Vision Care
InfantSEE
InHealth Ohio PPO Connect
Medicaid
Medical Mutual of Ohio
Medicare
MediGold
Meritain Health
MHBP
Multiplan
Mutual of Omaha
New Insurance
New Insurance
NGS, Inc. DMEPOS Operations, Medicare DMEPOS Claims
Ohio State Prime Care Advantage/NGS CoreSource
Optima Health
OptumHealth
PHCS
Physicians Mutual
PPO Connect
Railroad Medicare Part B Office
Revision
Spectera
Spectera Discount Plan
Standard Life and Accident Insurance Company
Starmark
Superior Vision
SuperMed Network
TLC
Tricare
UMR
United Healthcare
UPMC Health Plan
USA Senior Care
USAA
VSP
VSP Access Plan
Worker's Comp
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:
Additional Insurance
Insurance Information
Insurance Name:
None
New Insurance
New Insurance
New Insurance
AARP
Advantica
Aetna
Aetna Vision Network
Anthem
Aultcare
Avesis
Banker's Life and Casualty
Block Vision
Blue Cross Blue Shield
Cigna
Cigna Vision
Coresource
Davis Vision
Davis Vision Discount Plan
DMC
EyeMed
EyeMed Discount Plan
Golden Rule Insurance Co
Health Span
HealthCare Solutions Group
HealthPartners
Highmark Blue Cross Blue Shield Vision Claims
Humana
Humana Vision Care
InfantSEE
InHealth Ohio PPO Connect
Medicaid
Medical Mutual of Ohio
Medicare
MediGold
Meritain Health
MHBP
Multiplan
Mutual of Omaha
New Insurance
New Insurance
NGS, Inc. DMEPOS Operations, Medicare DMEPOS Claims
Ohio State Prime Care Advantage/NGS CoreSource
Optima Health
OptumHealth
PHCS
Physicians Mutual
PPO Connect
Railroad Medicare Part B Office
Revision
Spectera
Spectera Discount Plan
Standard Life and Accident Insurance Company
Starmark
Superior Vision
SuperMed Network
TLC
Tricare
UMR
United Healthcare
UPMC Health Plan
USA Senior Care
USAA
VSP
VSP Access Plan
Worker's Comp
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 answer none if question does not apply.
Patient Medical Information
Referred By:
Primary Care Physician and exam date:
Medication and Seasonal Allergies:
Medical History Have you experienced any of the following: Headache, Arthritis,Asthma,Diabetes,High Blood Pressure,Heart Disease,Inflammatory Bowel Disease,Seizures,Thyroid,Pregnant,Nursing,HIV+
Current medications, including vitamins:
Do you smoke?
Current every day smoker
Current some day smoker (not daily)
Former smoker (no longer smokes)
Heavy smoker (>10 cigs/day)
Light smoker (<10 cigs/day)
Never smoker (<100cigs quiv)
Smoker (current status unknown)
Unknown if ever smoked
Do you drink alcohol?
Do you use recreational drugs?
Preferred Language:
English
French
German
Spanish
Other
Family History
Describe family history and which family member has the following history: Ex...(Diabetes-Father)
Family Medical History:
Family Eye History:
Family Patients:
Patient Ocular Information
Eye History
Have you experienced: Sting, Burn, Itch, Surgery,Injury,Cataracts,Lazy Eye, Floaters, Glaucoma, Retinal Problems
Current Eye Medications:
Last Eye Doctor and exam date:
Primary Vision Correction:
Bifocals
Contacts
Contacts - Mono
None
Progressives
Single Vision
Trifocals
Are you interested in contact lenses?
Yes
No
Have you ever worn contacts lenses?
Yes
No
What type of contact lenses have you worn in the past?
Do you have a backup pair of glasses for your contact lenses?
Yes
No
Do you currently wear sunglasses?
Yes
No
Are you interested in Laser Vision Correction?
Not Interested
Yes
Any additional information
Submit Data