Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

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Home Phone

Preferred Contact Method

Birthday

Last 4 of SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Preferred Pharmacy

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

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Medical History

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Eye History

Reason for Visit *This field is required

Primary Reason

Secondary Reason

Do you currently have any of these eye symptoms?

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Do you currently take any of these medications?

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Have you had any eye surgeries? Please describe

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Last Eye Exam

Last Appointment Type

By Doctor

Primary Vision Correction

Do you:

Have Backup Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Medical History:

Medications

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Over the Counter Medications

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Vitamins

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Drug allergies

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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

*This field is required

Hypertension

*This field is required

High Cholesterol

*This field is required

Thyroid Conditions

*This field is required

Heart Conditions

*This field is required

Cancer

*This field is required

Year Diabetes Diagnosed

Other

Family Medical History

Unknown Family History

Does anyone in your family have any of these medical conditions?

Hypertension

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

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

Macular Degen

Glaucoma

Retinal Detach

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

General

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Skin

*This field is required

Ear/Nose/Throat

*This field is required

Respiratory

*This field is required

Musculoskeletal

*This field is required

Psychiatric

*This field is required

Endocrine

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Blood/Lymph

*This field is required

Neurological

*This field is required

Immune

*This field is required

Genitourinary

*This field is required

Gastrointestinal

*This field is required

Cardiovascular

*This field is required

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

Patient Signatures

Optomap

I understand that Advanced Eye Care of Covington requires Optomap Retinal Imaging for all routine examinations, and the fee for this service is $39 - which I am responsible for.

I authorize treatment of the person named above and agree to pay all fees and charges for said treatment. I authorize payment by my insurance to Advanced Eye Care of Covington for treatments and charges performed. I understand that I am responsible for all charges, regardless of how my insurance processes the claim. I indicate that i have read this Billing and Payment policy.

Patient Signature: Date:

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

View Notice of Privacy Practices Form (You Will Be Redirected To A New Page.)

The law requires that Advanced Eyecare of Covington make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:

I have read or had explained to me prior to any services offered Advanced Eyecare of Covington's Notice of Privacy Practice and agree to continue my care with Advanced Eyecare of Covington under said terms.

I authorize release of my information to the following individuals:

Name: Relationship:
Name: Relationship:
Name: Relationship:

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

Patient Signature: Date:

If you are signing as a personal representative of the patient, please indicate your relationship.

Representative To Patient: