Online Patient Forms

Patient information

First name

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Last name

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Birth Sex

Male Female

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Full Address

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City

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State

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Zip Code

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Please enter only 10 digits, including the area code. Do not enter any dashes or spaces. Do not enter the number 1 in front of the phone number

Cell Phone

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Type None if you Decline^

Birthday

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Full SSN

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If you don't have a Social Security Number, Please enter "None"

Please choose from the menu options or select the option to type in your own text. Thank you!

Medical History

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Eye History

Primary Reason for visit

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Location:

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Severity:

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Duration:

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Context:

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Do you currently have any of these eye symptoms?

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What eye medications are you currently taking? If you are not taking any, please type "None" in the box

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Medical History:

Do you have any of these medical conditions?

Diabetes

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Hypertension

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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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Family Medical History

Unknown Family History

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

Hypertension

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Diabetes

*This field is required

Thyroid

*This field is required

Cancer

*This field is required

High Cholesterol

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Heart Conditions

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Family Eye History

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

Macular degeneration

*This field is required

Glaucoma

*This field is required

Retinal detachment

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Blindness

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Cataracts

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Lazy/Crossed Eye

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Social History

Smoking Status

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Preferred Language

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Notice of Privacy, Policies and Agreement

Patient acknowledges that

It is the patient's responsibility to check if we are out-of-network with their insurance plan prior to their visit.
It is the patient's responsibility to file insurance claims if we are not contracted with your insurance company.

I understand that all charges for professional services rendered are my responsibility. I understand this office, if contracted with my insurance company, will file a claim to my insurance company on my behalf.

I authorize payment of benefits to Eric Verret OD, Inc.

Your doctor will accept the fee approved by your insurance as payment in full for any covered services. The patient will be responsible for any amount approved but not paid by the insurance as well as the full amount for all non-covered services.

I agree to assume responsibility for co-payments and deductibles as specified by my insurance and for the charges of any non-covered services.

I Agree

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NOTICE OF PRIVACY PRACTICES

Please read our Notice of Privacy

I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices and that I will be offered a copy of any amended Notice of Privacy Practice at each appointment.

I Agree

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RELEASE OF MEDICAL INFORMATION

I authorize release of my medical information to the following persons.

Name:

Phone number:

Relationship:

I Agree

Name:

Phone number:

Relationship:

I Agree

Name:

Phone number:

Relationship:

I Agree

PHYSICIAN PATIENT ARBITRATION AGREEMENT

please read our Patient Arbitration Agreement

I Agree

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Signature:

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Date:

Patient information

Billing information

Please choose from the menu options or select the option to type in your own text. Thank you!

Medical History

Please choose from the menu options

Eye History

Medical History:

Do you have any of these medical conditions?

Family Medical History

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

Family Eye History

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

Social History

Notice of Privacy, Policies and Agreement

Patient acknowledges that

NOTICE OF PRIVACY PRACTICES

RELEASE OF MEDICAL INFORMATION

PHYSICIAN PATIENT ARBITRATION AGREEMENT