Online Patient Form
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Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
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
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
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
Misc/Guardian
Referred By:
Referring Doctor:
Are any family members seen by our office?:
Billing Information
Is The Billing Address the Same?
Yes
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
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
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Vision Insurance Information
Insurance Name:
None
New Insurance
AARP Discount Plan
advantica
Aetna
Always vision Care
Amacore Vision
assurant health
avesis
Block Vision
Blue Cross Blue Shield
Central United Life
cigna
coast to coast
CompBenefits
coresource
Coventry Health Care
Davis Vision
entrust
envolve (opticare)
Eyemed Vision Care
First Look/Always Care
Humana
medicare
mertain ins
MES Vision
METLIFE-VSP
mycomp benefits
non traditional medicaid
NVA
Opticare
other ins
PHCS Network
principal ins
QualChoice
safeguard
sisco
Spectera
Superior Vision
svp- medicaid
Traditional Medicaid
UMR
United Health Care Medical
united healthcare community plan (texas star)
Vba VISION BENEFITS
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 Insurance Information
Insurance Name:
None
New Insurance
AARP Discount Plan
advantica
Aetna
Always vision Care
Amacore Vision
assurant health
avesis
Block Vision
Blue Cross Blue Shield
Central United Life
cigna
coast to coast
CompBenefits
coresource
Coventry Health Care
Davis Vision
entrust
envolve (opticare)
Eyemed Vision Care
First Look/Always Care
Humana
medicare
mertain ins
MES Vision
METLIFE-VSP
mycomp benefits
non traditional medicaid
NVA
Opticare
other ins
PHCS Network
principal ins
QualChoice
safeguard
sisco
Spectera
Superior Vision
svp- medicaid
Traditional Medicaid
UMR
United Health Care Medical
united healthcare community plan (texas star)
Vba VISION BENEFITS
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
Interested In Contact Lenses?
Yes
No
Ever Worn Contact Lenses?
Currently
Prior
Never
If yes, type of contacts worn in past:
Disposables
Extended Wear
Gas Permeables
Gas Perm Bifocals
Gas Perm Bitorics
Gas Perm FS Toric
Monovision - Soft
Monovision - Disposables
Monovision - Gas Perm
No CL Hx
Soft Daily Wear
Soft Torics
Other
Do you have backup glasses?:
Yes
No
Other
Brand/Power of Contacts: (if known)
Primary Vision Correction:
Bifocals
Contacts
Contacts - Mono
None
Progressives
Single Vision
Trifocals
Other
Do you want sunglasses?:
Yes
No
Do you want computer glasses?:
Yes
No
Do you have problems with glare?:
Yes
No
Interested in Laser Vision Correction?:
Yes
No
Do you currently have or have a history of the following conditions/symptoms?:
None
Itching
Burning, Stinging
Amblyopia
Eye Injuries
Eye Surgery
Flashes Of Light
Floaters
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Macular Degeneration
Other
Do you take any eye medications?:
None
Acular
Artificial Tears
Betoptic-S .25%
Betoptic .5%
Betagan
Erythromycin
FML
FML Forte
Gentamicin
Neosporin
None
Ocupress
Pilo Gel
Propine
Polytrim
Pred Mild
Pred Forte
Patanol
Timoptic .25%
Timoptic .5%
Tobradex
Voltaren
Xalatan
Other
Last Eye Doctor:
Primary Care Physician:
Do you take any other medications?:
Do you have any allergies?:
Please describe any history of conditions such as asthma, diabetes, thyroid disease, etc.:
Family Med History:
Arthritis
Cancer
Diabetes I
Diabetes II
Hypertension
Hypercholesterolemia
Heart Disease
Other
Family Eye History:
None
Amblyopia
Cataracts
Glaucoma
Macular Degeneration
Retinal Detachment
Weak Eye
Lazy Eye
Other
Review of Systems
General:
None
Fatigue
Fever
Loss of Appetite
Weight Gain
Weight Loss
Developmental Disorders
Other
Ears/Nose/Throat:
None
dry mouth
cough
ear ache
hard of hearing
stuffy nose
Other
Cardiovascular:
None
High BP
racing
pulse
Other
Respiratory:
None
congestion
short of breath
wheezing
Other
Genitourinary:
None
frequent urination
impotence
painful urination
yellow jaundice
Other
Musculoskeletal:
None
arthritis
cramps
joint pain
stiffness
swelling
Other
Skin:
None
growths
pimples, warts
rash
Other
Neurological:
None
headache
numbness, paralysis
seizures
Other
Psychiatric:
None
anxiety
depression
insomnia
Other
Endocrine:
None
diabetes
hypothyroid
Other
Blood/Lymph:
None
anemia
bleeding
cholestrolemia
Other
Allergy/Immune:
None
hives
itching
lupus
redness
sneezing
swelling
Other
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