Online Patient Form Patient InformationThank you for choosing Valley Eye Associates for you eyecare needs. Please complete this form in ink. If you have any questions or concerns, please do not hesitate to ask for assistance. We will be happy to help you. *All fields with an star are required. Today's Date* Date Format: MM slash DD slash YYYY Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last SexFemaleMaleSSNDate of Birth* Date Format: MM slash DD slash YYYY AgeEmail* Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneWould you like to receive text confirmations?YesNoPreferred Phone Number--Please Select--HomeCellWorkRace African American Asian Hispanic American Indian Caucasian Pacific islander Marital Status--Please Select--MarriedDivorcedSingleWidowedEmployer Name & AddressPosition/DepartmentSpouse/Parent's NameSpouse/Parent's Work/Cell PhoneStudentYesNoName of SchoolGuarantor (Person Financially Responsible)If Self: Skip this section.Name First Last Relationship to PatientParentSpouseOtherPhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Medical Insurance InformationPrimary InsurancePrimary Policy HolderMember IDPrimary's SS#Primary's Date of Birth Date Format: MM slash DD slash YYYY Secondary InsurancePrimary Policy HolderMember IDPrimary's SS#Primary's Date of Birth Date Format: MM slash DD slash YYYY Vision InsuranceVision Insurance ProviderPolicy or ID NumberPatient Medical History & Review of SystemsMedical DoctorMedical Doctor's PhoneDate of Last Physical Date Format: MM slash DD slash YYYY Date of Last Eye Exam Date Format: MM slash DD slash YYYY Chief ComplaintHow can we help you today? In this space, please briefly tell us any signs and symptoms you are experiencing.(Medical insurance will only cover your visit if there is a medical reason for the exam such as loss of vision, headaches, eye redness, eye pain, floaters, dry eye, eye itching or burning, glaucoma, cataracts, etc)History of Present IllnessWhich eye has a problem?Right EyeLeft EyeBoth EyesDoes the problem cause vision loss or blur?LossBlurDid the problem occur suddenly or gradually?SuddenGradualHow severe is the problem?MildModerateSevereIs it worse at any specific distance?DistanceNearBothHow long does it last?IntermittentConstantHow long has the problem been occuring?Short TermLong TermAre there associated symptoms?NoHeadachesNauseaDoes anything help the problem?Nothing helpsNothing has been triedGlasses & ContactsAre you thinking of getting GLASSES today?*YesNoAre you thinking of getting CONTACTS today?*YesNoDo you currently wear glasses?YesNoWhen do you wear your glasses? All the Time Reading/Near Work Only Computer Work Work Safety Distance Tasks Only Driving Other Please ExplainHave you ever worn contacts?YesNoBrandContact Lens Solution UsedAre you interested in wearing contact lenses?YesNoWhat style? Soft Gas Permeable Extended Wear Bifocal Color Disposable Astigmatic Unsure Do you work at a computer or video display terminal?YesNoIn which hobbies or sports do you participate?Medical InformationPlease Check any conditions that apply to you: Allergies (seasonal) Allergies (environmental) Drug Allergies (please list below) Pregnant Have given birth in last 6 months Breastfeeding Sinus Trouble Do you currently take any medications?*NoYesPlease list current medications:Name, Dosage and Frequency. Do you have any drug allergies?*YesNoPlease list all known drug allergies: Please list any major surgeries or hospitalizations:Past Ocular HistoryPlease select all that apply: Cataracts Glaucoma Macular Degeneration Diabetic Eye Disease Retinal Detachment Lazy Eye Eye Surgery Laser Treatments Eye Injury Chemo/Radiation Severe Ocular Pain Sensitivity to Light Floaters or Spots Flashes of Light Poor Distance Vision Poor Near Vision Eye Infection or Disease Double Vision Eye Burn, Itch, or Water Eye Strain Other Please explain:Family Ocular/Medical HistoryPlease select all that apply: Glaucoma Cataracts Macular Degeneration Retinal Detachment High Blood Pressure High Cholesterol Diabetes Thyroid Problems Heart Disease Cancer Other Please explain:Social HistorySmokingNoYesPacks a dayYearsAlcoholNoSocialOccasionalHeavyDrinks per day:Review of SystemsPlease select all that apply or fill in the blank for those not listed.Constitutional Flu Fever Fatigue Headache Recent Weight Change Select if you currently have.Endocrine Thyroid Diabetes Other Year diagnosed:Other:Ears, Nose, Throat Hearing Problems Sinus Throat Genitourinary Prostate Problems Kidney Stones Hysterectomy Cardiovascular Chest Pain Palpitations High Blood Pressure High Cholesterol Heart Failure Pace Maker Heart Attack Angioplasty/Bypass Valve Disease Carotid Artery Disease Neurological Stroke Weakness Seizure Multiple Sclerosis Skin Rash Itch Lesion Growth/Tumors Respiratory Shortness of Breath Asthma Emphysema Cough Bronchitis Pneumonia Tuberculosis Psychiatric Dementia Alzheimer's Depression Anxiety Schizophrenia Bipolar Hematologic Anemia Sickle Cell Bleeding Abnormality Elevated Cholesterol Gastrointestinal Heartburn Bowel Problems Inflammatory Bowel Disease Gall Bladder Problems Hepatitis Musculoskeletal Joint Pain Rheumatoid Arthritis Back Pain Fractures Marfan's Syndrome Ankylosing Spondylitis Immunology Immune Deficiency Lupus Sjogren's Other Please Explain Other:CancerYesNoType:HIV ExposureYesNoSTD ExposureYesNoType:AuthorizationI certify that I have read and understood the above information to the best of my knowledge. I certify that the above questions have been accurately answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize the doctor to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eyecare to third party payers and/or health practitioners.*Signature of Responsible PartyDate* Date Format: MM slash DD slash YYYY Agreement of ResponsibilityPlease View Our Agreement of Responsibility HereI have been informed by Valley Eye Associates and the Notice of Privacy Practices (see forms below) which contains a more detailed description of the uses and disclosures of my health information. I have been given the right to review and sign this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that Valley Eye Associates restricts how my private information is used or disclosed to carry out treatment, payment, or health care options. I also understand that Valley Eye Associates is not required to agree to my request restrictions, but if Valley Eye Associates does agree then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, excluding the extent in which Valley Eye Associates has already taken action relying on this consent.*Signature of Patient (Or Responsible Party)Date* Date Format: MM slash DD slash YYYY Payment PolicyPlease View Our Payment Policy HereI authorize the release of information to determine liability for payment and/or to obtain reimbursement. I understand that if my account is not paid directly, I am responsible for the full amount and may be charged all costs including attorney/collection agency fees incurred with collection of the amount due. I authorize the release of any medical information necessary to process claims and the release of payment to Valley Eye Associates or the physician rendering services.*Signature of Patient (Or Responsible Party)Date* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.
