Optix Optometry Patient Info Form

Welcome!
Patient Information
Date:

MonthDayYear
Legal name:*

First NameLast Name
Preferred name (if different):
Birth date:*

MonthDayYear
Age:
Gender (required by insurance companies):*

MaleFemale
Last 4 of SSN (use 0000 for minors or if you do not have an SSN):*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell phone (or home phone if you do not have a cell phone):*
E mail:*
example@example.com
Marital status:*

SingleMarriedDomestic partnerDivorcedWidowed
Are you a student?*

YesNo
Where do you go to school?*
Where do you work?*
What is your occupation?*
Emergency contact:*
Emergency contact phone number:*
How do you know this person?*
Financial and Insurance Information
Who is responsible for payment / who is the primary insured?*

SelfOther
What is their name?*

First NameLast Name
Birth date of the primary insured:*

MonthDayYear
Date
What is their relationship to the patient?*
Do they live at the same address as you?*

YesNo
What is their address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is their cell or home phone number?*
Do you have insurance?*

YesNo
Name of insurance company:*
Member #:*
Group #:
If possible, attach an image of the front AND back of your health insurance card here:

Browse Files

Cancelof
Eye Health History
Have you been to Optix before?*

YesNo
Name of previous eye doctor:
Approximate date of last eye exam:
Do you wear glasses?*

YesNo
Do you wear contact lenses?*

YesNo
Are you interested in wearing contact lenses?*

YesNo
Have you had LASIK, PRK or RK?*

YesNo
Have you ever had any eye injuries or other eye surgeries?*

YesNo
Briefly describe your eye injury or type of eye surgery:*
Check any boxes if you have recently experienced or have been diagnosed with any of the following with your glasses or contact lenses on:

Bloodshot eyesBlurred vision - distance or far awayBlurred vision - near or up closeBurning in eyesCataractsCrossed eyesDischarge from eyesDizzy spellsDouble visionDry eyesEye infectionEye strainFainting spellsFloaters or spots in visionGlaucomaMigraine headachesHeadachesItchy eyesLight sensitivityPoor color visionPoor night visionRed eyesSeeing flashes of lightSeeing halosTemporary loss of visionTwitching eyelidWatering eyes
Health History
Name of general practitioner or doctor:
Are you adopted and not aware of your family medical history?

YesNo
Please indicate if you or any blood relatives have been diagnosed with any of the following medical conditions:
ADD or ADHD

YourselfBlood relative
Hay fever

YourselfBlood relative
Artificial heart valve

YourselfBlood relative
Heart condition or pacemaker

YourselfBlood relative
High blood pressure

YourselfBlood relative
High cholesterol

YourselfBlood relative
Stroke

YourselfBlood relative
Cancer

YourselfBlood relative
Diabetes

YourselfBlood relative
Thyroid condition

YourselfBlood relative
Blindness

YourselfBlood relative
Cataracts

YourselfBlood relative
Retinal disease

YourselfBlood relative
Glaucoma

YourselfBlood relative
Lazy eye or amblyopia

YourselfBlood relative
Macular degeneration

YourselfBlood relative
Poor color vision

YourselfBlood relative
Gastrointestinal condition

YourselfBlood relative
HIV or AIDS

YourselfBlood relative
Hepatitis

YourselfBlood relative
Kidney disease

YourselfBlood relative
Currently pregnant

Yourself
Shingles

YourselfBlood relative
Skin condition

YourselfBlood relative
Artificial joints

YourselfBlood relative
Rheumatoid arthritis or lupus

YourselfBlood relative
Autism

YourselfBlood relative
Epilepsy

YourselfBlood relative
Mental condition

YourselfBlood relative
Depression

YourselfBlood relative
Asthma

YourselfBlood relative
Emphysema or COPD

YourselfBlood relative
Tuberculosis

YourselfBlood relative
Chemical dependency

YourselfBlood relative
Migraine headaches

YourselfBlood relative
Please list any other pertinent health information:
Do you smoke?*

YesNo
Do you drink alcohol?*

YesNo
Medications
Do you take any medications, including eye drops?*

YesNo
List any medications you take, including eye drops:*
Do you have any medical allergies?*

YesNo
List any medical allergies - medications, latex, etc:*
Please take a moment to review our Optomap Retinal Screening Policy.
Optomap Retinal Screening Policy - effective October 1, 2020.*

I understand the Optomap retinal screening will be performed at each annual/comprehensive eye exam and that routine retinal screening is not covered by health insurance. The charge is the lesser of my vision plan co-pay or $39. If a higher resolution scan is acquired and billed to my health insurance, I may owe a different amount subject to co-pay or deductible.
Late Cancellation and Missed Appointment Policy*

Appointments are in high demand as we are now booked out several weeks. We have unfortunately experienced a significant increase in missed appointments and last minute cancellations. It is unfair that everyone else now has to wait longer for their appointment. Optix Optometry has decided to institute a policy for late cancellations or missed appointments. If 24 hours advance notice is not given, there will be a $50 fee for each missed appointment. Missed appointments will not be rescheduled until any fees are paid.
Authorization, Financial Policy and HIPAA Statement
I authorize Drs. Steve and Stacey Beck to release any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such eye care to third party payers for the purpose of payment, and/or health practitioners until otherwise requested in writing. I assign all insurance benefits, if any, to Drs. Beck otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Optix Optometry requires payment in full for examination fees and all materials at the time of service or ordering. We accept cash, checks, money orders, Visa, Master Card and Discover. An overdraft fee of $25.00 will be assessed for returned checks. Client(s) will be responsible for any balances owed. If balances are not paid, the client will be responsible for all collection agency fees and attorney fees totaling an additional 25% of the current account balance at the time the account is sent to collections.

All patients who wear or elect to wear contact lenses will be enrolled in the Contact Lens Care Program and will be assessed any applicable professional fees related to contact lens fitting and evaluations.

“I have read the Optix Optometry HIPAA Notice of Privacy Policy posted either on the web site or in the office waiting area.”

“I have read the contents of this page and understand by signing my name, I agree to all of the terms and conditions.”
By checking the next box, you agree to the terms of Authorization, Financial Policy and HIPAA Statement.*
Enter your full first/last name to electronically sign this form - use guardian's full first/last name if completing for a minor:*
Date:

MonthDayYear
Should be Empty:

Welcome!

Patient Information

Financial and Insurance Information

Eye Health History

Health History

Medications

Authorization, Financial Policy and HIPAA Statement