Vision Source Eyecenter

Vision Source Eyecenter

Secure Form

Please select the office you are visiting.
How did you hear about us?
- Yellow Pages
- Radio
- Newspaper
- TV
- Internet
- Insurance Company
- Referred by Doctor
- Friend/Family
Please list name of Doctor
Please list name of Friend/Family
Patient Details
Patient Name*
First Last
By what name would you like to be called?*
Patient Date of Birth*
Patient S. S. #
Gender
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Mobile Phone*
Email
Enter Email Confirm Email
How may we contact you?
- Text
- Email
- Home Phone
- Cell Phone
- Work Phone
Patient Employer
Patient Occupation
Work Phone
Emergency Contact
Emergency Contact Phone
Emergency Contact Relationship to Patient
Medical Insurance
Medical Insurance Policy #
Vision Insurance
Vision Insurance Policy #
Do you have:
- Flex Plan
- Cafeteria Plan
- Medical Savings Plan
Spouse or Patient: (Responsible Party)
Name
First Last
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
S.S. #
Phone
Date of Birth
Employer
Work Phone
Is this individual financially responsible for your account?
- Yes
- No
Primary Medical Dr.
Last Medical Exam:
If female: Pregnant or Nursing?
- Yes
- No
Last Eye Exam:
Where was your last eye exam? Dr/Office
Do you have any allergies to medications?
- Yes
- No
Explain
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):
Review of Systems: (Patient)
Eyes
Do you currently, or have you ever had any problems in the following areas:
- Glaucoma
- Cataract
- Eye Surgery/Laser
- Eye Injury
- Macular Degeneration
- Retinal Degeneration
- Crossed/Lazy Eye
- Blind Eye
- Loss of Vision
- Double Vision
- Flashing Lights
- Spots/Floaters
- Eye Pain/Ache
- Dryness
- Itching/Burning
- Excess Redness
- Excess Tearing
- Excess Lt. Sensitivity
Neurological
Do you currently, or have you ever had any problems in the following areas:
- Headaches
- Migraines
- Seizures
Blood/Lymphatic
Do you currently, or have you ever had any problems in the following areas:
- Anemia
- Bleeding/Clotting Problem
Gastrointestinal
Do you currently, or have you ever had any problems in the following areas:
- Diarrhea
- Constipation
Cardio/Vascular
Do you currently, or have you ever had any problems in the following areas:
- High Blood Pressure
- Heart/Vascular Disease
- Stroke
- Fainting
Allergic/Immunologic
Do you currently, or have you ever had any problems in the following areas:
- Allergies/Hayfever
- Chronic Cough
- Rheumatoid Arthritis
- Lupus
- Sjrogren's
Genitourinary
Do you currently, or have you ever had any problems in the following areas:
- Kidney/Bladder Probs
- Genital Problems
Respiratory
Do you currently, or have you ever had any problems in the following areas:
- Asthma
- Emphysema
- Chronic Bronchitis
- Sinus Congestion
- Dry Throat / Mouth
- Sleep Apnea
Psychiatric
Do you currently, or have you ever had any problems in the following areas:
- Anxiety/Depression
- Emotional/Psychologic
Constitutional
Do you currently, or have you ever had any problems in the following areas:
- Fever
- Weight Loss/Gain
- Cancer
Bones/Muscles
Do you currently, or have you ever had any problems in the following areas:
- Arthritis
- Joint/Muscle Pain
- Chronic Back Pain
Integumentary & Endocrine
Do you currently, or have you ever had any problems in the following areas:
- Skin Prob/Disorder
- Thyroid Problem/Surg
- Diabetes
If you answered YES to any of the above or have a condition not listed please explain:
Family History
Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
- Blindness
- Cataract
- Crossed Eyes
- Glaucoma
- Macular Degeneration
- Retinal Detachment
- Diabetes
- High Blood Pressure
- Heart Disease
- Arthritis
- Cancer
- Thyroid Disease
If yes, please list the relationship:
Do You Smoke?
- Yes
- No
Type / amount / how long
Are you a former smoker?
- Yes
- No
Corrective Lens History
Do you wear glasses?
- Yes
- No
How old are they?
Are you having any problems with them?
Are there ever times you would prefer to go without your glasses?
- Yes
- No
Do you wear contact lenses?
- Yes
- No
What type?
- Rigid
- Soft
- Disposable
- Extended Wear
How old are your present contacts?
How is your comfort on a scale of 1-10?
How is your vision?
How many hours per day do you spend on a computer or electronic device?
Please indicate your method of payment, as full payment is required at the time services are rendered
I understand and agree that, regardless of my insurance, I am ultimately responsible for the balance on my account for services rendered:
- Cash
- Check
- Bank Card
- Credit Card
FOR OUR OFFICE TO SUBMIT YOUR INSURANCE AND/OR MEDICARE YOU MUST SIGN BELOW
I certify that the information given by me in applying for insurance /or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits, and I authorize payment of these benefits directly to the Eyecenters, P.A. on my behalf for any services and materials furnished. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage (as indicated in Item 9 of the CMS-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer or agency shown, and authorizes my doctor to act as my agent, as above.
I have read and agree to the above*
Date*
Email
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