Online Patient Forms Demographics TitleFirstLastMISuffixNickname Mr. Mrs. Ms. Master Miss Dr. Rev. Fr. Address: Apt/Suite #: City: State: 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 ZipCode: Email: Cell Phone: Preferred Contact Method: Cell Phone Email SSN: Sex: Male Female Birthday: Occupation: Billing Information Is The Billing Address the Same? TitleFirstLastMISuffix Mr. Mrs. Ms. Master Miss Dr. Rev. Fr. AddressApt/Suite # CityStateZipCode 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: Medical Insurance Insurance Information Please select from the following Medical Insurance plans: Insurance Name: None Vision Insurance Only Aetna AlwaysCare Vision Plan Avesis Vision Plan Blue Cross Blue Shield Boon-Chapman Cigna Davis Vision (Not in Network) Envolve Vision Plan Eyemed Vision Plan Eyetopia Humana M.E.S. Vision Medicare Meritain Health Metlife National Vision Administrators Scott & White (Tier 2 Only) Spectera Vision Plan Superior Vision Plan Tricare Standard United Healthcare Vision Care Plan VSP 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: DOB: Employer/School: Vision Insurance Insurance Information Please select from the following Vision Insurance plans: Insurance Name: None Medical Insurance Only Aetna AlwaysCare Vision Plan Avesis Vision Plan Blue Cross Blue Shield Boon-Chapman Cigna Davis Vision (Not in Network) Envolve Vision Plan Eyemed Vision Plan Eyetopia Humana M.E.S. Vision Medicare Meritain Health Metlife National Vision Administrators Scott & White (Tier 2 Only) Spectera Vision Plan Superior Vision Plan Tricare Standard United Healthcare Vision Care Plan VSP 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: DOB: Employer/School: Medical History Last Eye Doctor: Primary Care Physician: Akin, Mark Caven David Martin Doesn't Have One Doesn't Remember E.R. David Enriquez Fred Martin Glaze Gray, Lynne Jeffrey Hallett Jess Thompson King Kangos Martinez Merryman None Ream Silverthorne Stavinoha Terry Sherman Winn Warren, Pamela Other Preferred Pharmacy Medications (including OTC): - No current medications Allergies: - No Known Drug Allergies Environmental Drugs Latex Molds None Perfumes Seasonal Other Preferred Language (Declined) English Spanish Smoking Status Current Every Day Smoker Current Some Day Smoker Former Smoker Never Smoker Smoker, Current Status Unknown Unknown if Ever Smoked Do Your Eyes Sting, Burn, Itch, Or Feel Dry? Have You Had An Eye Injury Or Been Diagnosed With Cataracts, Lazy Eye, Retinal Problems, Or Glaucoma? Do You Have a History Of Headaches? Arthritis? Asthma? Diabetes? High Blood Pressure? Heart Problems? Inflammatory Bowel Disease? Seizures? Thyroid Problems? Do You Smoke? Are You Pregnant? Are You Nursing? Are You HIV+? If Yes, Please List Below. Does Anyone In Your Family Have/Had Diabetes? Lupus? Cancer? High Blood Pressure? Heart Problems? Auto-Immune Disease? If Yes, Please List Below. Does Anyone In Your Family Have/Had Glaucoma? Macular Degeneration? Retinal Detachment? Other Retinal Disorders? If Yes, Please List Below. Any Other Relevant Information? Reading Symptoms I wear glasses Full time Part time Far only Near only Both If yes, age when first worn: 6 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years Other I wear contact lenses Full time Part time If yes, age when first worn: 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years Other I work on a computer Glasses worn: Yes No If yes, hours per day: 1 2 3 4 5 6 7 8 9 10 Other COVID-19 SCREENING Within The Last 14 Days Have You Experienced Any Of The Following Symptoms: Condition Yes No Fever Cough Shortness Of Breath Or Difficulty Breathing Chills Repeated Shaking With Chills Muscle Pain Sore Throat New Loss Of Taste Or Smell Have You Traveled In The Last 14 Days? Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days? Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days? Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis, Or Have You Been Asked To Quarantine? Submit Data / Patient Signatures Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below. Notice of Privacy Practices View Notice of Privacy Practices Form Patient Signature: Date:
