San Marino Optometry Intake

Patient Medical Intake Form

Please fill in the form below prior to your visit. For returning patients, we require all information to be updated yearly.
Name*

First NameMiddle NameLast Name
E-mail (if none, put "none"*
example@example.com
Date of Birth

MonthDayYear
Date
Gender*

FemaleMale
Occupation*
Contact Number:*

Area CodePhone Number
Phone Type*

CellphoneHome phoneWork phone
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In case of emergency...
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*

Area CodePhone Number
How did you hear about us?*

Internet SearchInsurance PanelYelpWalk ByWord of MouthFamily/FriendMy Primary Care DoctorReturning patientOther
Who may we thank for referring you?
How would you like to be reminded of future appointments?*

TextEmailPhone CallPost Card
Insurance Plans
What is your vision insurance plan?*

None (Private pay)VSPEyemedMESSpecteraTricareI'm not sureOther
What is your medical/health insurance plan?*

I will not be using insurance/Not ApplicableI don't have medical insuranceBlue Cross Blue ShieldAnthemCignaUnited Health CareTricareMedicareI'm not sureOther
ID number for Medical Insurance
ID number for Vision Plan
Are you the primary member on the insurance plan?*

YesNoNot applicable
If not, provide the name of the primary insurance holder, their DOB and last four of their SSN
Last four digits of your SSN *optional, this allows us to verify VSP/Eyemed insurance benefits*
Insurance / Managed Care Financial Acknoledgement
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.*

Yes I consentI will not be using insurance for today's visit.
Health History
Date of your last physical (approximate)
Name of your Primary Care Physician

Medical History

Rows	Self	Family	Both	None
Diabetes
Pre-diabetes
Hypertension
High Cholesterol
Thyroid disorder
Heart Condition
Cancer
None
Other

Ocular History

Rows	Self	Family	Both	None
Lazy Eye
Cataracts
Glaucoma
Macular Degeneration
Eye Surgery
Eye Injury
LASIK/Refractive surgery
Retinal Disease
None
Other

Date of last eye exam (approximate)
Name of your last eye doctor
Do you experience any of the following?*

Blurry distance/nearBurning eyesDry eyesRed eyesItchy eyesEyestrain/headachesDouble visionNoneOther
Do you have medication allergies?*

YesNo
List medication allergies
Do you take any medications?*

YesNo
Please list all medications or please bring a copy of your medication to your visit.
I would like to learn more about:

Contact lensesFree LASIK consultationDry eye therapyNear-sightedness/myopia control (Ortho K)Other
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).*

Yes I agreeNo
Please read our privacy policy and sign below.
I have read and agree to the office's privacy policy. (Parents/guardian please sign for minor.)*
Should be Empty:

Patient Medical Intake Form

Insurance Plans

Insurance / Managed Care Financial Acknoledgement

Health History

Patient Notice