Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	TX 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 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
Primary Doctor	No Doctor Assigned Dr. Nguyen, Son Dr. Yang, Stan	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

City	State	ZipCode
	TX 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 UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary Medical Insurance

Insurance Information

Insurance Name:	None Adventist Health exam Blue Cross exam Blue Shield exam Empire Eye & Laser Exam EyeMed HealthEdge HELP Program Exam Lightspeed Medicare MES Private Pay Safeguard Superior Vision Tricare Medicare Supplement UFCW United Health Care exam VSP
Insurance Plan:
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

Insurance Information

Insurance Name:	None Adventist Health exam Blue Cross exam Blue Shield exam Empire Eye & Laser Exam EyeMed HealthEdge HELP Program Exam Lightspeed Medicare MES Private Pay Safeguard Superior Vision Tricare Medicare Supplement UFCW United Health Care exam VSP
Insurance Plan:
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:

Vision Insurance

Insurance Information

Insurance Name:	None Adventist Health exam Blue Cross exam Blue Shield exam Empire Eye & Laser Exam EyeMed HealthEdge HELP Program Exam Lightspeed Medicare MES Private Pay Safeguard Superior Vision Tricare Medicare Supplement UFCW United Health Care exam VSP
Insurance Plan:
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!

Patient Medical History

What is your PRIMARY reason for choosing our office?	Our Apple or Android App Online reviews Location Doctor reputation Our website Convenient office hours Friend/family recommendation Provider for your insurance Frame selection Acuvue.com Advertisement
Referring Doctor:

Interested In Contact Lenses?	Yes No
Ever Worn Contact Lenses?	Yes No
Brand of contact lens worn in past:

Interested in Laser Vision Correction?

No Yes Not Interested at this time

Eye History(Injuries, Surgeries, Glaucoma, Macular Degeneration, "Lazy Eye", Retinal Detachments, etc...):

Eye Medications:	None Allergy OTC Antibiotics Artificial Tears Glaucoma Steroid
Last Eye Exam:	1st Eye Exam 1 Year 2 Years 3 Years 4 Years 5-10 years More than 10 years Don't Know
Last Eye Doctor:	None Alexandrakis, George Allen, Louis Bakersfield Eye Institute BeSpectacled Calloway Eyecare Don't Know Dedonato, Larry Empire Eye & Laser Eyemart Fitch Eye Care German and Dehart Golden State Eye Holliwell, Kevin Icon Eyecare Innovative Eye Care JC Penny Ken's Optical Lenscrafters Li and Liao Park, Mark Premier Eyecare Ratty, Steven Sears Optical Southwest Eye Care Stainer, Gregory Stanton Optical Stockdale Optometry Sutter, Penelope Target Optical Triangle Eye Institute Vision Essentials Walmart Wood, Ed

Last Wellness Check-up by a physician:

Less than 1 year 1 year 2 years 3 years 4 years 5-10 years More than 10 years Don't Know

Primary Care Physician:
Allergies?:

Current Daily Medications:	Medical/Health Conditions (Pregnancy, Diabetes, Hypertension, Cancer, Heart Disease, etc...):
Family Medical History (Heart Disease, Cancer or Diabetes?):	Family Eye History (Glaucoma, Macular Degeneration, "Lazy Eye", etc...)

Anything else you would like us to know regarding your eyes or vision?:

Lifestyle

Patient Lifestyle Information

What is your professional environment?	I work in a professional business office I work outside most of the time My job requires travel (driving, flying, both?) Student Stay at home Mom Hospital/Clinic Other
How much time are you on a screen(Computer, Smartphone, iPad/tablet, TV)?	0-1 hr. 1-3 hrs. 3-5 hrs. 5-8 hrs. 8+ hrs. Other
How much time do you spend driving at night on a weekly basis?	0-1 hr. 1-3 hrs. 3-5 hrs. 5+ hrs. I avoid driving at night Other
What type of outdoor activities do you participate in?	Running/Walking/Jogging Golf Tennis Biking Team Sports(Football, baseball, Soccer etc) Recreational(Hunting, Hiking, Camping etc.) Other
What are your indoor hobbies?	Working out Indoor sports(Volleyball, wrestling, basketball etc.) Reading Video/Computer/phone games Crafting Baking/Cooking Watching TV/Movies Other
Personal Eyewear Style:	Professional Bold Fun Geek Chic/Nerdy Minimalistic Classy/Dressy Retro Other
I prefer colors that are?	Neutral and Subtle Fun and on trend Bright and Colorful Other

What did you like about your last pair of glasses?

What would you change about your last pair of glasses?

Patient Signature / Submit Data

ABOUT YOUR INSURANCE

There are two types of health insurance that will help pay for your eye care services and optical products. You may have both types and Bakersfield Eye Care Optometric Center accepts most insurance plans in both categories: 1) Vision plans (such as VSP, EyeMed and others) and 2) Medical insurance (such as Blue Cross/Blue Shield, Medicare and others).

Vision plans only cover routine vision wellness exams, along with eyeglasses and contact lenses. Vision plans do not cover medical eye care (the diagnosis, management or treatment of eye health problems). Medical insurance must be used for medical eye care. If some fees are not paid by your insurance, we will bill you for them, such as deductibles, co-pays or non-covered services as allowed by the insurance contract.

Please provide your insurance cards to our staff member so we can make a copy. We need to have your medical insurance card or Medicare card on file in case we should need it in the future for billing your insurance.

I have read and accept these policies.

ASSIGNMENT OF BENEFITS

I hereby assign all medical/vision benefits to which I am entitled, including Medicare, private insurance, or any other health/vision plans to Bakersfield Eye Care Optometric Center. I hereby authorize said assignee to release all information necessary to secure payment. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.

I understand that I am financially responsible for all charges not paid by my insurance, including non-covered services, such as refraction and contact lens evaluations.

AUTHORIZATION FOR THE USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby authorize the use and disclosure of individually identifiable health information relating to me, which is called Protected Health Information (PHI), under a federal privacy law. I further understand that my PHI may be used to carry out treatment, payment, or healthcare operations.

I understand that I may revoke this authorization at any time by notifying Bakersfield Eye Care Optometric Center in writing.

I have received a copy of Bakersfield Eye Care Optometric Center's Notice of Privacy Practices prior to signing this consent.

I understand I have the right to restrict how my PHI is used or disclosed by notifying Bakersfield Eye Care Optometric Center of my wishes in writing.

Patient Signature: Date:

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