Patient Medical Intake Form

Patient Medical Intake Form

Welcome to our office! We thank you for entrusting us with your eye care! Please fill the following form PRIOR to your visit. For returning patients, we require all information to be updated yearly.
PATIENT INFORMATION
Date of appointment*

MonthDayYear
Date
Name*

First NameLast Name
Birth Date*

MonthDayYear
Biological Gender*
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
How did you hear about us?

Family/Friend ReferralWalk byYELPGoogleInsuranceOther
INSURANCE
What type of vision plan will you be using?*

Cash pay / no insuranceIEHPVSPMES visionSpecteraLoma Linda Risk ManagementDavisMedicareOther
IF you are the primary on the insurance, we need to verify your insurance information. Please enter the last 4 digits of your SSN.
IF you are NOT the primary on the insurance: Please enter the (1) first and last NAME of the primary insurance holder, (2) their DOB and, (3) their last 4 digits of their SSN
What MEDICAL insurance do you have?*

Cash pay / no medical insuranceIEHPMedicareBlue Shield PPOCigna PPOAnthem Blue Cross PPOBlue Cross PPOAetna PPOUnited Health Care (UHC) PPOHMO Medical PlanOther
APPOINTMENT INFORMATION
Reason for visit:

Wellness eye examinationGlasses examContact lens evaluationMedical visit (Please note that medical visits are not be covered by vision insurance plans)Dry Eye EvaluationMyopia Control EvaluationOther
OCULAR HISTORY
Are you experiencing any of the following (check all that apply):

NoneBlurry vision at distance/nearEyestrainHeadachesDry eyesBurning eyesRed eyesItchy eyesLight sensitivityFlashes of light/floatersOther
Are you interested in:

Contact lensesFree LASIK/PRK consultationDry eye evaluation and therapyVision therapyOther

Have you or your family been diagnosed with the following OCULAR/EYE conditions:

	NONE	Myself	Family	Both
Retinal defect/hole/tear
Glaucoma
Cataracts
Macular degeneration
Eye turn / lazy eye
Eye injury
Eye surgery

If you have had an eye surgery, please specify below:

NoneRefractive surgery (LASIK / PRK)Cataract surgeryRetinal repairStrabismus / Eye turn surgeryOther
MEDICAL HISTORY
Last physical:

Have you or your family been diagnosed with the following MEDICAL conditions:

	NONE	Myself	Family	Both
Pre-diabetes
Diabetes Type I/II
Hypertension
High Cholesterol
Thyroid disorder
Heart Condition
Cancer
Autoimmune disease

Are you taking medications?

No.Yes, I will list them below.
If so, please list Medications below (if none, write none):
Do you have any allergies and/or allergies to medications?

No.Yes, I will list them below.
Please list any allergies and reaction (if none, write none).
Please annotate any additional concerns that you would like the Doctor to address during your appointment:
Vision/Medical Insurance Financial Acknowledgement and Scheduling Policies
At Acute Vision Optometry, we believe you deserve the best eye care. Our goal is to always present you with the best eye care treatment options for your eye concerns and diagnosis. Please review the following carefully.
HIPAA Authorization
Contact Lens Evaluation

If you will be having a contact lens evaluation in addition to the glasses exam, please review our contact lens instructions/contract below.
Signature*

Clear
Hit the SUBMIT button below and you are done! (No need to print)

Thank you for your patience and cooperation. We look forward to seeing you at your appointment!
Should be Empty:

Patient Medical Intake Form

PATIENT INFORMATION

INSURANCE

APPOINTMENT INFORMATION

OCULAR HISTORY

MEDICAL HISTORY

Vision/Medical Insurance Financial Acknowledgement and Scheduling Policies

HIPAA Authorization

Contact Lens Evaluation