El Portal Optometry - Existing Patient Registration (Secured)

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All information is secure and in compliance with the California Consumer Privacy Act (CCPA) & Health Insurance Portability and Accountability Act (HIPAA)
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Patient Information UpdateLet us know who you are
First Name
Last Name
Date of Birth
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Contact Info UpdatePlease update your contact info
Email Address
Cell Phone Number
Home Phone Number
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No
Yes
Has you Address changed since your last visit?
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Address UpdateAll 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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Vision Insurance UpdatePlease take a photo or upload your VISION insurance card/info. Skip if you do not have VISION insurance.
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Medical Insurance UpdatePlease 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 Evaulation
Diabetic Eye Evaluation
Dry Eye Evaluation and/or Treatment
Other
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Appointment Info
What is the reason for your visit?
Please Select
Please Select
Yes, I want to renew my contacts
No, I don't use contacts
No, but I want to try contacts
Do you use Contact Lenses, or want to?
Occupation (to better assess visual demands)
How many hours a day spent on computer or digital screen?
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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
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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Medical History Update
Please Select
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No
Yes
Has your Medical History or Medication changed since your last visit?
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No
Yes
Do you have Diabetes?
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No
Yes
Do you have High Blood Pressure?
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No
Yes
Do you have High Cholesterol?
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Medical History UpdatePlease choose all that apply
NONE
Diabetes
High Blood Pressure
High Cholesterol
Thyroid
Cardiovascular
Respiratory
Gastrointestinal
Immunologic
Endocrine
Genitourinary
Lymphatic
Musculoskeletal
Neurological
Psychological
Cancer
Other
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Medication Update
List any medications. Please type "None" if none are taken
List any ALLERGIES to medications. Please type "None" if you have no known allergies
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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 El Portal Optometry or insurance company to release any information required to process my claims. I have reviewed the policies & warranties and 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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