VOEC - Existing Patient (Secured)

1
Patient Information UpdateAll information is secured and in compliance with the California Consumer Privacy Act (CCPA) & Health Insurance Portability and Accountability Act (HIPAA)
First Name
Last Name
Date of Birth
2
Contact Info UpdatePlease update your current contact info
Email Address
Home Phone Number
Cell Phone Number
No
Yes
Has you Address changed since your last visit?
3
Address Update 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
Please Select
Please Select
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
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
Curacao
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
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
4
COVID-19 ASSESSMENT* This field is required.
No
Yes
Refuse to Answer
Have you received the COVID-19 vaccination?
5
COVID-19 SCREENING ASSESSMENT* This field is required.
No
Yes
Have you had a Fever Greater than 100 within the last 14 days?
No
Yes
Have you had a Dry Cough or Difficulty Breathing within the last 14 days?
No
Yes
Have you had Difficulty Breathing within the last 14 days?
6
Medical History Update* This field is required.
No
Yes
Has your Medical History changed since your last visit?
No
Yes
Do you have Diabetes?
No
Yes
Do you have High Blood Pressure?
No
Yes
Do you have High Cholesterol?
7
Appointment Info
What is the reason for your visit?
Yes, I want to renew my contacts
No, I don't use contacts
No, but I want to try contacts
Do you wear Contact Lenses, or want to?
Occupation (to better assess visual demands)
How many hours a day spent on computer?
8
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
9
Medical History UpdatePlease let us know if you have any medical conditions
NONE
Diabetes
High Blood Pressure
High Cholesterol
Thyroid
Cardiovascular
Respiratory
Gastrointestinal
Immunologic
Endocrine
Genitourinary
Lymphatic
Musculoskeletal
Neurological
Psychological
Cancer
10
Medical History Update
List any medications. Please write "None" if none are taken
List any ALLERGIES to medications. Write "None" if none are taken
11
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.
12
Advanced Digital Eye Exam* This field is required.***COVID SAFETY SAFETY PRECAUTION: To maintain proper distancing from the doctor during your exam and to reduce your time inside the office, all routine eye exams will require a mandatory Optos retinal imaging to your eye health evaluation (reduced fee of $25) *** Valley Optometry Eyecare is committed to providing you with the best eye care using the latest advanced technology available. We perform Advanced Digital Eye Exams w/ Optomap Retinal Imaging to better track your eye health. The additional fee is $30. By clicking, you acknowledge that you have reviewed, or had the chance to review, a copy of the office's Advance Digital Eye Exam Policy and agree to its terms.
13
Acknowledgement* This field is required.The above information 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 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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