Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Marital Status

Misc/Guardian

Emergency Contact Name and Number

Whom may we thank for referring you?

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:

Primary Vision Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

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Eye History

What is the main reason for your visit today?

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Do you currently have any of these symptoms?

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Do you currently take any of these eye medications?

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Please list any eye surgeries and/or trauma (include dates)

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Last Eye Exam

By Doctor

Ophthalmologist

Last Visit

Primary Vision Correction

What type of glasses do you wear?

How old are your glasses?

Do you wear contacts?

*This field is required

Contact Lens Wearers Only

What solution do you use?

Do you have backup glasses?

How often do you sleep in your contacts?

How often do you replace your contacts?

Family Eye History

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

Macular Degeneration

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Glaucoma

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Retinal Detachment

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Blindness

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Cataracts

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Lazy/Crossed Eye

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Medical History:

Medications - No Medications

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Drug Allergies - No known drug allergies

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Vitamins -

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Over the Counter Medications -

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Please describe any injuries or surgeries you have had: -

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Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Do you have any of these medical conditions? -

Diabetes

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Year Diabetes Diagnosed

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HbA1c

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High Blood Pressure

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High Cholesterol

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Thyroid Conditions

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Heart Conditions

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Cancer

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Other

Family Medical History

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

High Blood Pressure

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Diabetes

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Thyroid

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Cancer

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High Cholesterol

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Heart Conditions

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Other

Review Of Systems

General

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Skin

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Ear/Nose/Throat

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Respiratory

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Musculoskeletal

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Psychiatric

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Endocrine

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Blood/Lymph

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Neurological

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Immune

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Genitourinary

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Gastrointestinal

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Cardiovascular

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Social History

Hobbies

Smoking Status

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Type

How long

Alcohol Use

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Type

How long

Illegal Drug Use

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Type

How long

Race

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Ethnicity

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Preferred Language

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STDs

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Policies, Consent, Submit Data

MISCELLANEOUS

Whom may we thank for referring you?

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FINANCIAL DISCLAIMERS

We will attempt to verify your insurance eligibility for services and/or materials before your appointment. Verification of eligibility is done as a courtesy only and is not a guarantee of payment. Please check with your plan administrator if you have any questions regarding your eligibility.

Initial

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LIABILITY
I understand Leet EyeCare will bill my vision and/or health insurance. I know that I am responsible for any remaining balance after the claim is submitted. Should my insurance not cover the services that are submitted in full, I agree to pay any outstanding balance.
In cases of divorce, the individual who receives the care is responsible for all charges. We will not bill a divorced spouse for the patient's services. For minor patients, the responsible party bringing the minor patient to the clinic will be responsible for any co-pays or co-insurance at time of service.

Initial

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PRIVACY POLICY
In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for services, and to conduct health care operations involving our office. The Privacy Policy describes these uses and disclosures in detail. I acknowledge that I have been offered and/or received a copy of the Privacy Policy from Leet EyeCare.

The following people are authorized to speak on behalf of my account / treatment plan:

Name

Relation To Patient

Phone #: Account / Treatment Plan

Name

Relation To Patient

Phone #: Account / Treatment Plan

Initial

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REFRACTION FEE (MEDICARE/MEDICAL INSURANCE ONLY)
The part of your examination that determines your prescription is called a refraction. A refraction is also done under certain circumstances for diagnostic purposes. If you have routine vision benefits such as VSP or EyeMed, your refraction is typically included with your exam benefits. Medical insurances that do not include routine vision benefits, such as Medicare, do not cover a refraction. The fee for a refraction is $39.

Initial

RETINAL HEALTH SCREENING

The Optomap retinal health screening allows our doctors to provide the highest level of care and is mandatory for all new patients (age allowing). This screening enables us to detect retinal disease at an earlier state making it essential in the prevention and management of eye health for our patients. The fee for this screening is $39. Currently, there are few vision insurances which pay for this screening. Leet EyeCare will bill your vision insurance when applicable.

Initial

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CONTACT LENS EVALUATION FEE (CURRENT CONTACT LENS WEARERS ONLY)

The contact lens evaluation is separate from the health portion of your examination and requires an additional prescription. This fee includes the additional testing, fitting assessment, and new contact lens prescription which allows you to purchase contact lenses for up to one year from the date of the evaluation. Leet EyeCareÃ¢ÂÂs fee for the contact lens evaluation starting at $70, however most vision insurances have a specified copay dependent upon your contact lenses.

Initial

Patient / Guardian Signature

Date

Patient information

Billing information

Primary Vision Insurance

Primary Medical Insurance

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Eye History

Contact Lens Wearers Only

Family Eye History

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

Medical History:

Do you have any of these medical conditions? - All No

Family Medical History

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

Review Of Systems

Social History

Policies, Consent, Submit Data

Do you have any of these medical conditions? -