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*

Cell PhoneHome PhoneWork Phone
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?*

YesNo
How did you find out about our office?*

Family/Friend referralReferral from another officeYELPGoogleWalk byInsuranceReturning patientOther
Insurance
What type of insurance will you be using? Note: We do not accept Kaiser insurance.*

None (private pay)IEHPVSPEyeMedMES VisionSpecteraRisk ManagementDavisSuperior VisionTricareMedicare PPOBlue Cross Blue Shield PPOOther
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*

Annual routine eye examThis is a medical visit (office visit) - please note that medical visits will not be covered by your vision insurance.
Do you experience any of the following? (Select all that applies)*

Blurry distance/nearBurning eyesDry eyesItchy eyesRed eyesWatery eyesNoneOther
I am interested in learning more about:

Contact lensesFree LASIK ConsultationOther
Medical + Eye History

Medical History

	Self	Family	Both	None
Diabetes
Pre-Diabetes
High blood pressure
High cholesterol
Thyroid disorder
Heart condition
Cancer
None
Other

Eye History

	Self	Family	Both	None
Lazy Eye
Cataracts
Glaucoma
Macular Degeneration
Eye Surgery
Eye Injury
Retinal Disease
None
Other

Do you have drug allergies?*

NoYes
Please list any allergies
Do you take any medications?*

NoYes
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.*

Yes I ConsentI will not be using insurance for today's visit.
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 ConsentNo I Do Not Consent, I will inform the staff on how to send my records at time of request
I consent to received appointment reminders and patient communications via text message (messaging rates may apply) and/or emails, postcards.*

Yes I ConsentNo I Do Not Consent
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)*

Clear
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.*

Yes I Agree To The Cancellation / No Show Policy
Should be Empty:

Patient Medical Intake Form

Insurance

Appointment Type

Medical + Eye History

Insurance / Managed Care Financial Acknowlegement

Patient notice

Cancellation Policy Policy