Premier Eye Care Optometry Intake

Patient Medical Intake Form

Please fill the form below prior to your visit. For returning patients, we require all information to be updated yearly.
First Name
Last Name
Gender
Date of birth (Month, Date, Year)
Phone Number

Area CodePhone Number
Phone Type
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail Address (write "none" if you do not have an email)
Occupation:
Are you a new patient?
How did you find out about our office?

Other
Insurance
What type of insurance will you be using? Note: We do not accept Kaiser insurance.

Other
To verify your insurance, please input the last 4 digits of your social security
If you are not the primary on your insurance, please enter the name of the primary insurance holder, their DOB and the last 4 digits of their social.
When was your last eye exam (approximate date)
Name of your last eye doctor:
If you wear contact lenses, please enter the contact lens brand:
Appointment Type
Select the appointment type(s) you require
Do you experience any of the following? (Select all that applies)

Other
I am interested in learning more about:

Other
Medical + Eye History

Medical History

Eye History

Do you have drug allergies?
Please list any allergies
Do you take any medications?
Please list all medications or please bring a copy of your medication to your visit.
Insurance / Managed Care Financial Acknowlegement
I authorize payment for my vision and or medical benefits be paid directly to the Doctor. I agree that if my employer, insurance carrier, or plan sponsor denies payment of all or any portion of my claim, I will be financially responsible for all outstanding charges. Authorization obtained at time of service does not guarantee payment.
Patient notice
I consent that exam records such as (referrals, reports, medications Rx, glasses/contact lenses prescription) can be sent to me digitally (via email).
I consent to received appointment reminders and patient communications via text message (messaging rates may apply) and/or emails, postcards.
Please read and sign our Privacy Practice Policy
I have read and agree to the office's privacy policy. (Parents/guardian please sign for minor)
Cancellation Policy Policy
I understand that I will give the office a call at 909-799-3130 (please leave a voicemail during after hours) or email us at premiereyecareoptometry@gmail.com if I need to make changes or cancel to my appointment within 12 hours of the appointment. No shows without timely notice will incur a $25 no show fee. Exceptions will be provided on a case by case basis. We thank you for your understanding.
Should be Empty:

Patient Medical Intake Form