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Demographics
Patient Information
Title
First
Last
MI
Suffix
Nickname
Pronoun
Mr.
Mrs.
Ms.
Dr.
Rev.
he/him/his
she/her/hers
they/them/theirs
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:
Text Message
Cell Phone
Email
Work Phone
Home Phone
Other Phone
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
Misc/Guardian
Drivers License #
Is the Billing Address Different?
Billing Information
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Copy Address From Above
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
Insurance Information
Insurance Name:
None
AARP Medicare Complete
AARP Supplement
Aetna
Aetna Medicare
All Savers UHC
Allied Benefit Systems
American Republic Ins Co
Amerigroup
Ameritas
Avesis Vision
Bankers Life And Casualty
BCBS NE
Block Vision
Bright Health
Champus
Cigna Health Ins Co
Comp Benefits
Corporate Diversified
Emphesys-principal Hc,inc-ppo
Ex-omaha Hc Service Ctr-f
Eyemed-Cole Vision Services
Golden Rule
Great-west Life & Annuity
HCFA-1500
Heartland Plains
Humana Gold Choice
Mail Handlers Benefit Plan
Manhattan Life
MEDICA
Medico
Meritain Health
Met Life
Metra Health
Metropolitan Life Ins Co
Mid-american Benefits,inc
Midlands Benefit Administrator
Midlands Choice
Mo-kan Sheet Metal Workers
Mutual of Omaha
Mutually Preferred/ppo
Noridian Adm Services
Option One-ppo
Physicians Mutual Ins Co
Principal Life Ins Co.
Prudential Ins Co-aarp
Qual Choice
RR Medicare-Palmetto Gba
Secure Horizons/uhc
Spectera
Steamfitters Lo #464
The Benefit Group
The Eye Health Network
Think Whole Person Health
Tricare for Life
Tricare West Region
UhC-choice+,select+
UHC Advantage Medicare Complete
UHC Ins Co-options PPO
UMR
United Health ONE
UPREHS
Vsp Vision Service Plan
WPS Medicare of NE
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
Insurance Information
Insurance Name:
None
AARP Medicare Complete
AARP Supplement
Aetna
Aetna Medicare
All Savers UHC
Allied Benefit Systems
American Republic Ins Co
Amerigroup
Ameritas
Avesis Vision
Bankers Life And Casualty
BCBS NE
Block Vision
Bright Health
Champus
Cigna Health Ins Co
Comp Benefits
Corporate Diversified
Emphesys-principal Hc,inc-ppo
Ex-omaha Hc Service Ctr-f
Eyemed-Cole Vision Services
Golden Rule
Great-west Life & Annuity
HCFA-1500
Heartland Plains
Humana Gold Choice
Mail Handlers Benefit Plan
Manhattan Life
MEDICA
Medico
Meritain Health
Met Life
Metra Health
Metropolitan Life Ins Co
Mid-american Benefits,inc
Midlands Benefit Administrator
Midlands Choice
Mo-kan Sheet Metal Workers
Mutual of Omaha
Mutually Preferred/ppo
Noridian Adm Services
Option One-ppo
Physicians Mutual Ins Co
Principal Life Ins Co.
Prudential Ins Co-aarp
Qual Choice
RR Medicare-Palmetto Gba
Secure Horizons/uhc
Spectera
Steamfitters Lo #464
The Benefit Group
The Eye Health Network
Think Whole Person Health
Tricare for Life
Tricare West Region
UhC-choice+,select+
UHC Advantage Medicare Complete
UHC Ins Co-options PPO
UMR
United Health ONE
UPREHS
Vsp Vision Service Plan
WPS Medicare of NE
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:
Tertiary
Insurance Information
Insurance Name:
None
AARP Medicare Complete
AARP Supplement
Aetna
Aetna Medicare
All Savers UHC
Allied Benefit Systems
American Republic Ins Co
Amerigroup
Ameritas
Avesis Vision
Bankers Life And Casualty
BCBS NE
Block Vision
Bright Health
Champus
Cigna Health Ins Co
Comp Benefits
Corporate Diversified
Emphesys-principal Hc,inc-ppo
Ex-omaha Hc Service Ctr-f
Eyemed-Cole Vision Services
Golden Rule
Great-west Life & Annuity
HCFA-1500
Heartland Plains
Humana Gold Choice
Mail Handlers Benefit Plan
Manhattan Life
MEDICA
Medico
Meritain Health
Met Life
Metra Health
Metropolitan Life Ins Co
Mid-american Benefits,inc
Midlands Benefit Administrator
Midlands Choice
Mo-kan Sheet Metal Workers
Mutual of Omaha
Mutually Preferred/ppo
Noridian Adm Services
Option One-ppo
Physicians Mutual Ins Co
Principal Life Ins Co.
Prudential Ins Co-aarp
Qual Choice
RR Medicare-Palmetto Gba
Secure Horizons/uhc
Spectera
Steamfitters Lo #464
The Benefit Group
The Eye Health Network
Think Whole Person Health
Tricare for Life
Tricare West Region
UhC-choice+,select+
UHC Advantage Medicare Complete
UHC Ins Co-options PPO
UMR
United Health ONE
UPREHS
Vsp Vision Service Plan
WPS Medicare of NE
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
Medical History
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
What is your Gender?
Male
Female
Phone Number
*
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Today's Eye Exam
Want Glasses
Want Contact Lenses
Eye Health Check
Other
Eye Injury
Right Eye
Left Eye
Both
None
Explain
Eye Turn or Lazy Eye
Right Eye
Left Eye
Both
Not Sure
None
Other
Glaucoma
Cataract
Macular Degeneration
Surgery
None
Other
Explain any of the above:
Family Ocular History:
Glaucoma
Macular Degeneration
Lazy Eye or Eye Turn
Other
None
Explain:
Patient Medical History:
Diabetes
Heart Condition
High Blood Pressure
Thyroid Condition
Cancer
Other
None
Explain Above
Family Medical History:
Diabetes
Heart Condition
High Blood Pressure
Cancer
Other
None
Explain Above
Are you currently taking any medication?
*
Yes
No
Medication (List purpose of medication if unsure of name)
Do you have any medication allergies?
*
Yes
No
Not Sure
Are you pregnant or nursing?
*
Yes
No
Pupil dilation improves the doctor's ability to examine the inside structures of the eye for signs of disease. Dilation is recommended for first time eye exams, persons with certain health conditions such as diabetes and at regular intervals for all persons. The effect of the dilation drops will typically last 4-6 hours and will include sensitivity to light and the inability to focus up close. In some cases distance vision may also be blurred. We will provide disposable sunglasses for light sensitivity.
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