Online Patient Form
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After completing all the forms, please submit your data on the final tab. Thank you!
Demographics
Patient Information
Title
First
Last
MI
Suffix
Preferred Name
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address:
City:
State/ZipCode
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
TX
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell 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
Guardian
Emergency Contact
Name:
Phone Number:
Is the Billing Address Different?
Billing Information
Address Same As Above
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address
City
State
ZipCode
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
TX
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Vision Insurance
Primary Vision Insurance Information
Insurance Name:
None
AARP
Advantica
Aetna
American Republic Insurance Company
Amerigroup Community Care
Ameritas Group
APWU
Assurant Health
Avesis
bcbs of alabama
Beechtree
Blue Cross and Blue Shield of Illinois
Blue Cross Blue Shield
Blue Cross Blue Shield of Michigan
blue cross blue shield of north carolina
BlueBell health benefits
c
Champva
Cigna
Colonial Penn Life Insurance Company
Community Health Alliance
consenco
Continental Life Insurance
Davis Vision
EyeMed
freedom medicare supplement
Golden Rule Insurance Company
GWH- Cigna
Health Alliance
Health Cost Solutions
healthscope benefits
Humana
Independent Health
Logistics Health
Mail Handlers Benefit Plan
March Vision
Medicare
Meritain Health
Mutual of Omaha
National Vision Administrators
NECA-IBEW
Panamerican Life
Patriot Coal
Physician's Mutual
POMCO
Prairie States
Principal Financial
Priority Health Insurance Company
Signature Health Alliance
Simple
Smart Health
Spectera Eyecare
Superiorvision
The Empire Plan - United HealthCare
Tri-Care
TriWest (WPS-VAPCCC)
UGS-Global Care Inc.
UHC Community Plan
UMR
UMWA
united american
United Health Care
Vision Benefits of America
Vision Care Plan
Vision Service Plan
Viva Health
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 Vision Insurance Information
Insurance Name:
None
AARP
Advantica
Aetna
American Republic Insurance Company
Amerigroup Community Care
Ameritas Group
APWU
Assurant Health
Avesis
bcbs of alabama
Beechtree
Blue Cross and Blue Shield of Illinois
Blue Cross Blue Shield
Blue Cross Blue Shield of Michigan
blue cross blue shield of north carolina
BlueBell health benefits
c
Champva
Cigna
Colonial Penn Life Insurance Company
Community Health Alliance
consenco
Continental Life Insurance
Davis Vision
EyeMed
freedom medicare supplement
Golden Rule Insurance Company
GWH- Cigna
Health Alliance
Health Cost Solutions
healthscope benefits
Humana
Independent Health
Logistics Health
Mail Handlers Benefit Plan
March Vision
Medicare
Meritain Health
Mutual of Omaha
National Vision Administrators
NECA-IBEW
Panamerican Life
Patriot Coal
Physician's Mutual
POMCO
Prairie States
Principal Financial
Priority Health Insurance Company
Signature Health Alliance
Simple
Smart Health
Spectera Eyecare
Superiorvision
The Empire Plan - United HealthCare
Tri-Care
TriWest (WPS-VAPCCC)
UGS-Global Care Inc.
UHC Community Plan
UMR
UMWA
united american
United Health Care
Vision Benefits of America
Vision Care Plan
Vision Service Plan
Viva Health
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 Insurance
Primary Medical Insurance Information
Insurance Name:
None
AARP
Advantica
Aetna
American Republic Insurance Company
Amerigroup Community Care
Ameritas Group
APWU
Assurant Health
Avesis
bcbs of alabama
Beechtree
Blue Cross and Blue Shield of Illinois
Blue Cross Blue Shield
Blue Cross Blue Shield of Michigan
blue cross blue shield of north carolina
BlueBell health benefits
c
Champva
Cigna
Colonial Penn Life Insurance Company
Community Health Alliance
consenco
Continental Life Insurance
Davis Vision
EyeMed
freedom medicare supplement
Golden Rule Insurance Company
GWH- Cigna
Health Alliance
Health Cost Solutions
healthscope benefits
Humana
Independent Health
Logistics Health
Mail Handlers Benefit Plan
March Vision
Medicare
Meritain Health
Mutual of Omaha
National Vision Administrators
NECA-IBEW
Panamerican Life
Patriot Coal
Physician's Mutual
POMCO
Prairie States
Principal Financial
Priority Health Insurance Company
Signature Health Alliance
Simple
Smart Health
Spectera Eyecare
Superiorvision
The Empire Plan - United HealthCare
Tri-Care
TriWest (WPS-VAPCCC)
UGS-Global Care Inc.
UHC Community Plan
UMR
UMWA
united american
United Health Care
Vision Benefits of America
Vision Care Plan
Vision Service Plan
Viva Health
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 Medical Insurance Information
Insurance Name:
None
AARP
Advantica
Aetna
American Republic Insurance Company
Amerigroup Community Care
Ameritas Group
APWU
Assurant Health
Avesis
bcbs of alabama
Beechtree
Blue Cross and Blue Shield of Illinois
Blue Cross Blue Shield
Blue Cross Blue Shield of Michigan
blue cross blue shield of north carolina
BlueBell health benefits
c
Champva
Cigna
Colonial Penn Life Insurance Company
Community Health Alliance
consenco
Continental Life Insurance
Davis Vision
EyeMed
freedom medicare supplement
Golden Rule Insurance Company
GWH- Cigna
Health Alliance
Health Cost Solutions
healthscope benefits
Humana
Independent Health
Logistics Health
Mail Handlers Benefit Plan
March Vision
Medicare
Meritain Health
Mutual of Omaha
National Vision Administrators
NECA-IBEW
Panamerican Life
Patriot Coal
Physician's Mutual
POMCO
Prairie States
Principal Financial
Priority Health Insurance Company
Signature Health Alliance
Simple
Smart Health
Spectera Eyecare
Superiorvision
The Empire Plan - United HealthCare
Tri-Care
TriWest (WPS-VAPCCC)
UGS-Global Care Inc.
UHC Community Plan
UMR
UMWA
united american
United Health Care
Vision Benefits of America
Vision Care Plan
Vision Service Plan
Viva Health
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 choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Date of Last Exam:
Last Eye Doctor:
Primary Care Physician:
Eye History: Do you have a history of any eye conditions? Please describe:
Medical History: Do you have a history of any medical conditions? Please describe:
Surgical History: Please describe any surgeries you've had.
Family Eye History:
Family Med History:
Do you have any allergies to medications?:
Do you take any eye medications?:
Do you take any other medications?:
Do you Smoke? If so, how much?
Do you drink alcohol? If so, how much?
Do you use recreational drugs? If so, explain?
Is there any other information you'd like to provide? If no, please leave blank:
Submit Data
After Completing All Forms Submit Data on Final Tab