Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

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Full Address

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Apt/Suite #

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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Home Phone

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Type None if you Decline^

Preferred Contact Method

Birthday

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Full SSN

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

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Marital Status

Misc/Guardian

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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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Secondary Reason

Location:

Severity:

Duration:

Context:

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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Have you had any eye surgeries? Please describe

Last Eye Exam

Last Appointment Type

By Doctor

Primary Vision Correction

Do you want New Glasses?

Are you interested in contact lenses?

Are you interested in free lasik consultation?

Note: Most insurance plans either: Do not cover Contact Lens Evaluation or Require a copay.

Contact Lens Wearers only:

Brand of Contacts worn in the past

Medical History:

Medications No Medications

Over the Counter Medications

Vitamins

Drug allergies

Preferred pharmacy

Preferred pharmacy address

Preferred pharmacy phone number

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

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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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Year Diabetes Diagnosed

Other

Family Medical History

Unknown Family History

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

Hypertension

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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

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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Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Allergic/ Immuno

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

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Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

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STD

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

Signature:

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Date:

Patient information

Billing information

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Medical History

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Eye History

Contact Lens Wearers only:

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?

Review Of Systems

Social History

Notice of Privacy, Policies and Agreement

Patient acknowledges that

NOTICE OF PRIVACY PRACTICES

RELEASE OF MEDICAL INFORMATION

PHYSICIAN PATIENT ARBITRATION AGREEMENT