Online Appointment Form

Patient Appointment Form

Welcome to Dr. Teles' Office & Looking Glass Optical
Date of Appointment *

Month Day Year
Patient Information

Fill the form below indicating the appointment type you need. We will get back to you soon for follow-up/confirmation.
Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number (Home)
Phone Number (Work)
Phone Number (Cell)
E-mail Address *
Preferred Contact Method

Home Phone # Work Phone # Cell Phone # Email Address
Patient's SSN *
Drivers License/Government ID
Employer ( or School )
Occupation ( or Grade )
Spouse ( or Parent's ) Name
Spouse ( or Parent's ) Work
Date of Birth *

Month Day Year
Gender *
What is the major purpose of this visit? *
Any problems with your current contact lenses or glasses?
VERY IMPORTANT! NEW PATIENTS ONLY:
Who may we thank for referring you to our office?
If not referred, how did you choose our office?

Another Doctor Insurance List Saw Sign/Building Google Yelp
Insurance Information

Please note that most insurance does NOT cover the Contact Lens Follow-Up or the CL Evaluation.
Vision Insurance:
Subscriber Name
Subscriber ID Number
Subscriber Birth Date
Copy of Vision Insurance Card

Browse Files
Please upload front and back, accepted file types include: pdf, zip, jpg, jpeg, png, gif Cancel of
Primary Medical Insurance:
Subscriber Name
Subscriber ID Number
Subscriber Birth Date
Copy of Medical Insurance Card

Browse Files
Please upload front and back, accepted file types include: pdf, zip, jpg, jpeg, png, gif Cancel of
Do you participate in a flex spending account? *

Yes No
How will you settle your account today? *

Cash Check Credit Card
Lifestyle Questions
Do you……(check box if your answer is yes)

work at a computer? If yes, please complete computer questionnaire. have a problem seeing your computer with your progressive lenses? have a problem with glare at night?' think you might benefit from thinner, lighter lenses? have interest in a “test drive” of the latest contact lens designs spend time outdoors? How much? Hrs/week have prescription sunwear? prefer not to wear your glasses at times? want information on Laser Vision Correction surgery? have interest in a non-surgical approach to vision correction? have more than 1 pair of current Rx eyewear? have children? have family members in need of eyecare? have you had any surgeries? do you use cigarettes/tobacco?
Have you ever experienced, been diagnosed or treated for any of the following?

Blurry Vision Burning Cataracts Corneal Abrasions Crossed eye/Eye turn Double Vision Eye Infections Eye Injury Flash of light Floaters/Spots Glaucoma Grittiness Headaches Iritis/Uveitis Itchiness Lazy Eye Macular Degeneration Occasional dryness Retinal Detachment Sunlight Sensitivity Tearing Trouble seeing at night Uncomfortable glasses
The information in this confidential case history form is critical to the evaluation of your vision and health.
Patient Medical History
Name of Family Physician
Family Physician Practice Location
Date of Last Physical Check-up

Month Day Year
CURRENT MEDICATIONS (Rx or Over the Counter)
Allergies to medications?

Yes No
If so, what medications?
Have you had any surgeries?

Yes No
Do you use cigarettes/tobacco, alcohol, or other substances?

Yes No
Have you ever been diagnosed or treated for the following health problems?
Allergies

Yes No
Arthritis

Yes No
Blood/Lymph

Yes No
Bronchitis

Yes No
Cancer

Yes No
Cholesterol

Yes No
Diabetes

Yes No
Digestive

Yes No
Ears/Nose/Throat

Yes No
Endocrine

Yes No
Eczema/Rashes

Yes No
Fatigue

Yes No
Fevers

Yes No
Genitourinary

Yes No
High Blood Pressure

Yes No
Integumentary (Skin)

Yes No
Kidney

Yes No
Muscle/Bone

Yes No
Neurological

Yes No
Psychological

Yes No
Respiratory

Yes No
Sinus

Yes No
Throat Infections

Yes No
Thyroid

Yes No
Unusual weight losses/gains

Yes No
Patient Eye History
Date of Last Eye Exam

Month Day Year
Last Eye Exam Performed by whom?
Have you ever tried contact lenses?

Yes No
Do you currently wear contact lenses?

Yes No
If so, what kind?
Solutions used?
Are you satisfied with the vision and comfort of your contact lenses?

Yes No
Would you prefer clear contact lenses or colored contact lenses?

Yes No
If you wear bifocals, do the lines or head tilting bother you?

Yes No
Family Medical/Eye History (Select all that apply)

Is there a family medical history of any of the following:
Blindness

Yes, Mother's Side Yes, Father's Side No
Cataracts

Yes, Mother's Side Yes, Father's Side No
Corneal Problems

Yes, Mother's Side Yes, Father's Side No
Diabetes

Yes, Mother's Side Yes, Father's Side No
Glaucoma

Yes, Mother's Side Yes, Father's Side No
Heart Disease

Yes, Mother's Side Yes, Father's Side No
Lazy Eye

Yes, Mother's Side Yes, Father's Side No
Macular Degeneration

Yes, Mother's Side Yes, Father's Side No
Retinal Problems

Yes, Mother's Side Yes, Father's Side No
I confirm that the above information is correct and that I agree to the advisement below. *

Clear
Please verify that you are human *
Please be advised if you are using insurance coverage for your visit, this is a contract between you and your insurance company, not Looking Glass Optical or Dr. Mayer Teles.

If your insurance company has not reimbursed our office in full within 60 days, you are responsible for providing payment in full to Looking Glass Optical.
Should be Empty:

Patient Appointment Form

Patient Information

Insurance Information

Lifestyle Questions

Patient Medical History

Patient Eye History

Family Medical/Eye History (Select all that apply)