Lakeway Eye Center - Wally El-Hitamy, O.D.
Please use this form to update personal, insurance, and medical information
After you have filled in all 3 sections, please be sure to hit the SUBMIT button below.
Patient Personal Information
After filling out Date and Name(required), please let us know what changes we need to make since your last visit.
Date: (Required)
*
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Month
-
Day
Year
Date
Please Enter Your Name: (Required)
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Email
example@example.com
Employer/School
Occupation
Emergency Contact Name (or Guardian Name)
First Name
Last Name
Emergency Contact Phone Number (or Guardian Phone Number)
-
Area Code
Phone Number
Insurance/Vision Plan Information
Primary Medical Insurance:
Enter the name of your primary medical insurance carrier
Name of Policy Holder
First Name
Last Name
Relationship to Patient
Policy Holder Date of Birth
-
Month
-
Day
Year
Date
Policy Number
Group Number
Please attach pictures of your insurance card here (Front and Back)
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of
Vision Plan Name:
Please enter the name of your vision plan
Name of Policy Holder
First Name
Last Name
Relationship to Patient
Policy Holder Date of Birth
-
Month
-
Day
Year
Date
Member ID Number
Enter your member ID number, if available.
Please attach pictures of your Vision Plan card here (Front and Back)
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of
Medical Information
Medical History
Do you currently have any problems with the following? If not applicable, leave blank.
General: Fever, Weight Loss/Gain, Fatigue?
Eyes:
Ears, Nose, Mouth, Throat:
Allergies
Are you allergic to any medications?
Skin
Neurological
Cardiovascular
Respiratory
Gastrointestinal
Genitals, Kidney, Bladder
Musculoskeletal
Endocrine
Please tell us of any specific medical conditions for which you are being treated
Please lis your current medications
Please list any operations (location and estimated date)
Do you use tobacco?
No
Yes
Do you use alcohol?
No
Yes
Does anyone in your immediate family have
High Blood Pressure
Diabetes
Macular Degeneration
Glaucoma
Retinal Detachment
Cataracts
Any other eye contditions(explain below)
Use this space to expand on answers above
Estimated date of last exam?
Was that exam for
Glasses
Contacts
Both
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