Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

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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Medical History

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Eye History

Reason for Visit

Primary Reason

Secondary Reason

Do you currently have any of these eye symptoms?

Do you currently take any of these medications?

Have you had any eye surgeries? Please describe

Last Eye Exam

Last Appointment Type

By Doctor

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Medical History:

Medications No Medications

Over the Counter Medications

Vitamins

Drug allergies

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

Hypertension

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Year Diabetes Diagnosed

Other

Family Medical History

Unknown Family History

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

Hypertension

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

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

Macular Degen

Glaucoma

Retinal Detach

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

Policies, Consent, Submit Data

ACKNOWLEDGMENT OF RECEIPT

View Notice of Privacy Practices Form

I acknowledge that I received a copy of Greg Aker, O.D.,
Sarah Koehnemann, O.D., and Jennifer Bradley, O.D.,

Notice of Privacy Practices (HIPPA).

Patient Signature

*This field is required

Date

INSURANCE BILLING AUTHORIZATION FORM

I authorize Dr. Aker and Aker Eye Center, PA to bill by Insurance Carrier(s), Medicare and any secondary Insurance Carrier, on my behalf for this and all future visits to this office. This signature is to remain on file, as required as a future authorization.

Patient Signature

*This field is required

Date

Aker Eye Center Vision Source Downtown
338 S. Washington Ave. Titusville, Florida 32796
Aker Eye Center Vision Source Playalinda
1114 S. Washington Ave. Titusville, Florida 32796

I hereby authorize medical providers and personnel of Aker Eye Center Vision Source to discuss and/or release my protected health information with the following listed individual(s):

Name:

Relationship To Patient:

Name:

Relationship To Patient:

Name:

Relationship To Patient:

(Pt initials) I do not wish for my health information to be shared with any other parties aside from physicians whom I may need to be referred to during the course of my care.

I understand that I have the right to revoke this authorization, in writing at any time.

Patient Signature

*This field is required

Date

Aker Eye Vision Source
338 S. Washington Ave. Titusville, Fl. 32796
321-269-2021

MINOR MEDICAL CONSENT FORM

Minor's Full Legal Name:

Date Of Birth:

Parent / Legal Guardian:

• I do swear and declare on this day of

that I am the parent or legal guardian of above named minor and there are no court orders preventing me from granting this authorization. I hereby give my consent to treat above named minor for any medical care, testing, and administration of pharmaceutical intervention determined by a physician to be necessary for the welfare of the minor while under the care of Aker Eye Center.

• I understand that I have the right to revoke this authorization in writing at anytime during my child's care.

Signature of Parent / Legal Guardian:

Date: