Online Patient Form

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

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Text Message Cell Phone Email Work Phone Home Phone Other Phone
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
Misc/Guardian		Drivers License #

Is the Billing Address Different?

Billing Information

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Copy Address From Above
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:

Primary

Insurance Information

Insurance Name:	None
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:

Secondary

Insurance Information

Insurance Name:	None
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:

Tertiary

Insurance Information

Insurance Name:	None
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 select Other from the drop down to type multiple answers or your own text.

What is your main reason for visit?

no complaint blur at distance and near broken glasses burning distance blur double vision dryness failed DMV failed vision screening flashes floaters headache injury to eye itching laser vision consultation light sensitivity loss of vision lost glasses near blur pain redness referred by MD routine exam stinging strain tearing want new EG wants contact lenses Other

Do you wear glasses? Yes No Used To
If yes, how long? < 1 year 1 - 3 Years > 3 Years
if yes, do you wear them for: Dist Near Both

Do you have a back up pair of glasses? Yes No

Do you want thinner, lighter lenses? Yes NO

Do you wear sunglasses? RX Transitions No Rx

Do you wear Contact Lenses? Yes No Used To
Contact Lens Type:

Interested in Contacts? Yes No N/A

Date of Last Eye Exam?

Date of Last Medical Exam?

Do you have any allergies to medications? Yes No
List:


Do you have seasonal allergies? Yes No

Are you taking medications? Yes No

Are you pregnant? Yes No Nursing

Do you see flashes of light in your eyes? Yes No

Do you see floating objects in your eyes? Yes No

Do you have temporary blackouts of your vision? Yes No

Do yo uhave frequent headaches? Yes No

Do you smoke? Yes No

Do you drink alcohol? Yes No

Hours spent on digital device?

Occupation

List Meds

List Eye Meds

Do you play sports?

What are your hobbies?

Do You Have?
NONE
High Blood Pressure
Diabetes
Lung Disease
Cancer
Rheumatoid Arthritis
Sarcoidosis
Seizures
Multiple Sclerosis
HIV
Heart Disease
Thyroid Disease
Skin Disorder
Asthma
Cataracts

Have you ever had?
None
Strabismus (eye turn)
Amblyopia (lazy eye)
Keratoconus
Glaucoma
Diabetic Retinopathy
Macular Degeneration
Dry Eyes
Iritis
Retinal Detachment
Retinal Disease
Optic Nerve Disease
Blurry Vision
Double Vision
Halos
Glare
Light Sensitivity
Stinging Eyes
Gritty Eyes
Tired Eyes
Watery Eyes
Mucous Discharge
Itchy Eyes
Red Eyes
Eyelid Infections
Other Concerns:

Have you ever had eye surgery? Yes No
None
Cataract
Retinal Detachment
Muscle Surgery
Trauma
Lasik / PRK
Foreign Body Removal
Other

Prior Eye Doctor:

Major Hospitalizations:

Has anyone in your family ever had:

None	Parent	Sibling	Child
Blindness
Glaucoma
Diabetes
Cataracts
Macular Degeneration
Keratoconus
Arthritis
Cancer
Heart Disease
High Blood Pressure
Thyroid Disease
Skin Disorder
Asthma
Allergies
Eye Disease Injury
Lazy Eye
Eye Surgery

COVID - 19
1) Do you currently have a fever? Yes No

2) Do you currently have a cough or sore throat? Yes No

3) Have you traveled internationally or visited a high impact COVID state within the last 14 days? Yes No

4) Have you been in contact with someone with known or suspected COVID-19 / Coronavirus? Yes No

5) Do you live with or have you been around someone who has exhibited signs and symptoms of fever and / or respiratory infection such as a cough or sore throat? Yes No

Submit Data / 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

View Notice of Privacy Practices Form

Patient Signature: Date:

Patient Responsibility

Please note that all contact lens exams must be completed within 2 weeks. Exceptions may be granted due to extenuating circumstances, in which case, the appointment has to be completed within 4 weeks from the date of the first exam. Otherwise, a new fitting fee will be paid to continue the contact lens exam. Also note no refunds on contact lenses. All unopened contact lens boxes may be exchanged within 30 days.

Initial:

Please note that if you are using your insurance today, you will be responsible for all copays and services not covered by your insurance company, including the refraction fee, if using a medical insurance.

Initial:

Medicare patients, glasses, contacts, and refraction are not covered with your insurance plan.

Initial:

Please note that a 24-hour notice is required for all cancellation and rescheduled appointments. If 24-hour notice is not given, a $50 fee will apply.

Initial:

No refunds will be given on glasses; All glasses purchases are final.

Initial:

All glasses or prescription rechecks must be completed within 30 days

Initial:

If you are requesting paper copies of your health records please note that a $20 copy fee applies.

Initial:

If you are diabetic a retina photo will be taken during your examination .The fee for this procedure is $39.

Initial:

Signature: Date: