VOEC - New Patient (Secured)

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All information is secured and in compliance with the California Consumer Privacy Act (CCPA) & Health Insurance Portability and Accountability Act (HIPAA)
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Patient InformationAll information is secured and in compliance with the California Consumer Privacy Act (CCPA) & Health Insurance Portability and Accountability Act (HIPAA)
First Name
Last Name
Nickname
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Female
Male
Non-Binary
Gender
Date of Birth
SSN
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Address* This field is required.All information is secured and in compliance with the California Consumer Privacy Act (CCPA) & Health Insurance Portability and Accountability Act (HIPAA)
Street Address
Street Address Line 2
City
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Patient InformationAll information is secured and in compliance with the California Consumer Privacy Act (CCPA) & Health Insurance Portability and Accountability Act (HIPAA)
Email Address
Cell Phone Number
Home Phone Number
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Patient InformationTo better address your visual demands
Occupation (or Grade)
Please list any hobbies
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10 hours or more
7-9 hours
4-6 hours
0-3 hours
Daily hours spent on a computer / digital screen
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VISION Insurance InformationPlease take a photo or upload your VISION insurance card/info. Skip if you do not have VISION insurance.
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MEDICAL Insurance InformationPlease take a photo or upload your MEDICAL insurance card/info. Skip if you do not have MEDICAL insurance.
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What Is The Reason For Your Visit?Please choose all that apply
Annual Eye Examination
Contact Lenses: Renew Contact Prescription
Contact Lenses: New Wearer & Training
Medical Eye Condition
Myopia Control / Orthokeratology
Keratoconus / Specialty Contact Lenses
Glaucoma Evaluation
Diabetic Eye Evaluation
Dry Eye Evaluation / Treatment
Other
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Are you having any of these eye related conditions?Please choose all that apply
Blurry Vision at Distance
Blurry Vision at Reading
Blurry Vision at Computer
Eye Strain or Eye Fatigue
Dry Eyes
Burning Eyes
Itchy Eyes
Red Eyes
Teary Eyes
Seeing Flashes or Floaters
Headaches
Double Vision
Glaucoma
Macular Degeneration
Retinal Problems
LASIK
Keratoconus
Lazy Eye or Eye Turn
Other
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Patient Information
When was your last eye exam?
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Please Select
Yes
No
Do you wear eyeglasses?
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Please Select
Yes
No
Do you wear contact lenses?
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Prescription Glasses Information
How old are your current glasses?
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Please Select
No
Yes
Do you use Computer or Reading glasses?
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Please Select
No
Yes
Do you use Prescription Sunglasses?
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Contact Lens Information
What Contact Lens BRAND do you use?
What Contact Lens SOLUTIONS do you use?
How many hours a day do you wear your contacts?
How often do you replace your contacts?
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Do you have any medical conditions?* This field is required.Please choose all that apply
NONE
Diabetes
High Blood Pressure
High Cholesterol
Thyroid Issues
Cardiovascular
Respiratory
Gastrointestinal
Immunologic
Endocrine
Genitourinary
Lymphatic
Musculoskeletal
Neurological
Psychological
Cancer
Other
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Medical History Info* This field is required.
List any medications. Type "None" if none are taken.
List any ALLERGIES to medications. Type "None" if you have no known allergies.
Please Select
Please Select
No
Yes
Do you smoke?
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Please Select
No
Yes
Do you drink alcohol?
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Do you have a family history of the following?Please check all that apply
Nearsightedness/ Myopia
Cataract
Glaucoma
Macular Degeneration
Retinal Detachment
Lazy Eye or Eye Turn
Diabetes
High Blood Pressure
Cancer
Other
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How did you hear about our office?* This field is required.
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Insurance List
Saw Sign or Building
Referred by Someone
Google
Yelp!
Newspaper
Mailing or Flyer
Other
Please choose one
If you were referred, who?
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HIPAA Compliant Acknowledgement* This field is required.By clicking, you acknowledge that you have reviewed, or had the chance to review, a copy of the office's Notice of Privacy Practices and agree to its terms.
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Contact Lens Policy (Contact Lens Wearers Only)The FDA categorizes contact lenses as a medical device and requires an annual contact lens evaluation to renew any contact lens prescription. By clicking, you acknowledge that you have reviewed, or had the chance to review, a copy of the office's Contact Lens Policy and agree to its terms.
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Advanced Digital Eye Exam* This field is required.To provide you with the highest level of care, we require OPTOS digital retinal imaging to all routine eye examinations. The Optos technology allows our doctors to better monitor the health of your eyes for any potential retinal issues. Further, it will reduce your time inside the office and provide proper distance from the doctor. The copay has been reduced to $25. By clicking, you acknowledge that you have reviewed a copy of the office's Advance Digital Eye Exam Policy and agree to its terms.
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Electronic Delivery of Prescription* This field is required.I consent to receive an electronic copy of my eyeglass and/or contact lens prescription via email after my examination. I acknowledge that the prescription will be sent to the email address I provide and that I can contact the office if I need to update my email address or encounter any issues with receiving the prescription. Additionally, I understand that my prescription will be immediately available at the end of my examination through the online patient portal, which can be accessed from our website or by visiting https://www.revolutionphr.com/portal/welcome.htm
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Acknowledgement* This field is required.The information entered is true to the best of my knowledge. I authorize any insurance benefits to be paid directly to the physician and acknowledge that I am financially responsible for any balance not paid by my insurance company. I authorize Valley Optometry Eyecare Center or insurance company to release any information required to process my claims. I have reviewed the policies & warranties understand that all professional exam fees and sales of contact lenses and optical goods are non-refundable and due at time of services rendered.
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