Camarillo Vision Center; an optometric practice

Camarillo Vision Center; an optometric practice

Secure Form

New Patient Form

Step 1 of 4

25%

Patient Details
Patient Name*
First Last
Patient Date of Birth*
Is the Patient a Minor?
- No
- Yes
Legal Guardian Name
First Last
Contact Information
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Mobile Phone
OK to Contact Via Text Message?
Email
Enter Email Confirm Email
Preferred Contact Method
Do You Have an Emergency Contact?
- No
- Yes
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Demographics
Patient Occupation
Patient Gender
Patient Marital Status
Patient Race, Ethnicity
How Did You Hear About Our Office?
Who May We Thank for Referring You?
Insurance
- I have insurance
- I do not have insurance

Insurance Verification
Last Four Digits of Patient's Social Security Number
Vision Insurance
Vision Insurance Provider
Vision Insurance Member Name
Vision Insurance Member ID#
Vision Insurance Member Date of Birth
Medical Insurance
Name of Medical Insurance Provider
Medical Insurance ID#
Medical Insurance Policy or Group ID#
Medical Insurance Member Date of Birth
Medical Insurance Member Employer
Relationship to Medical Insurance Member
- Spouse
- Child

Exam History
When Was Patient's Last Eye Exam?
Does Patient Currently Wear Glasses?
- Yes
- No
How Often Does Patient Wear Glasses?
- Constantly
- Reading / Computer
- Driving
- Leisure / Fashion only
Does Patient Currently Wear Contacts?
- Yes
- No
Current Contacts Brand
Current Contacts Prescription
Are You Interested in Contacts?
- Yes
- No
Reason for Patient's Visit
Name of Patient's Primary Care Physician
Optical & Medical History
Has patient experienced, or been treated for, any of the following? Check all that apply.
Eye Conditions & Disorders
- Cataracts
- Crossed Eye
- Glaucoma
- LASIK or RK
- Lazy Eye
- Macular Degeneration
- Retinal Detachment
- Blurry Vision (Near or Far)
- Burning
- Discharge
- Double Vision
- Dryness
- Excess Tearing/Watering
- Eye Infection
- Eye Pain or Soreness
- Floaters or Spots
- Halos
- Headaches
- Itching
- Light Flashes
- Light Sensitivity
- Redness
- Sandy or Gritty Feeling
- Other
Medical Conditions
- AIDS/HIV
- Allergies
- Arthritis
- Asthma
- Blood/Lymph Disorder
- Cancer
- Diabetes
- Ears, Nose, Throat Conditions
- Gastrointestinal Conditions
- Heart Disease
- High Blood Pressure
- High Cholesterol
- Kidney Disease
- Lupus
- Neurological Conditions
- Psychiatric Disorder
- Seizures
- Skin Conditions
- Stroke
- Thyroid Dysfunction
- Other
Other Medical Conditions
Family History
Has any of patient's family members experienced, or been treated for, any of the following? Check all that apply.
- Arthritis
- Amblyopia
- Stroke
- Glaucoma
- Thyroid Disease
- High Blood Pressure
- Diabetes
- Cancer
- Lupus
- Kidney Disease
- Macular Degeneration
- Retinal Detachment
- Cataract
- Blindness
- Other
Medications & Vitals
Vitamins
Please indicate all recreational and over-the-counter vitamins.
- Aspirin
- Vitamin C
- Vitamin D
- Vitamin E
- Omega-E/Fish Oil
- Glucosamine
- Antihistamine
- Other Vitamins
Current Medications
List all medications and conditions being treated.
Medication Drug Allergies
Please include food, tape, latex, and dyes.
Is Patient Pregnant or Nursing?
- Yes
- No
Does Patient Smoke?
- Yes
- No
- Never
How Many Packs Per Day?
- 1
- 2
- 3
- 4
- 5 +
- Social
Does Patient Consume Alcohol?
- Yes
- No
How Many Drinks Per Week?
- 1
- 2
- 3
- 4
- 5 +
- Social

Privacy Policy
In the course of providing service to you, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for services, and to conduct healthcare operations involving our office. The Privacy Policy describes these uses and disclosures in detail.
- I acknowledge that I have been offered and/or received a copy of the Privacy Policy from Camarillo Vision Center
Financial Disclaimers
Eligibility for medical insurance and/or routine vision benefits
Liability*
- We will attempt to verify your plan eligibility for services and/or materials before your appointment. Verification of eligibility is done as a courtesy only and is not a guarantee of payment. Please check with your plan administrator if you have any questions regarding your eligibility.
  I understand that account balances and co-payments are due at the time of service. If I have medical insurance or routine vision benefits, I authorize my plan carrier to directly pay Dr. Schneider. I also authorize Dr. Schneider to release any information required for payment to be made. If my plan carrier does not pay, or partially pays, I understand I am responsible for payment in full or the remaining balance. Professional fees are non refundable. There is a 25% restocking fee for cancellation of any order once placed. I understand this agreement and he above financial disclaimers.
Contact Lens Fees*
- Contact lens evaluation services are not an included part of an eye health evaluation and vision assessment, and additional fees apply. Fees are customized according to the complexity of the case and the predicted time necessary to care for the individual patient. Fees for contact lens evaluation services range between $60 and $450. As with glasses, contact lens materials are an additional fee.
Refraction Fee*
- The part of your evaluation that determines your prescription is called a refraction. A refraction is also done under certain circumstances for diagnostic purposes. If you have routine vision benefits such as VSP, EyeMed or Medical Eye Services, your refraction is typically included with your exam benefits. Medical insurances that do not include routine vision benefits, such as Medicare, do not cover a refraction. The fee for a refraction is $25.
Phone
This field is for validation purposes and should be left unchanged.