Online Appointment Form

Patient Appointment Form

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

MonthDayYear
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 NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
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*

MonthDayYear
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 DoctorInsurance ListSaw Sign/BuildingGoogleYelp
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 Cancelof
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 Cancelof
Do you participate in a flex spending account?*

YesNo
How will you settle your account today?*

CashCheckCredit 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 designsspend time outdoors? How much? Hrs/weekhave 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 VisionBurningCataractsCorneal AbrasionsCrossed eye/Eye turnDouble VisionEye InfectionsEye InjuryFlash of lightFloaters/SpotsGlaucomaGrittinessHeadachesIritis/UveitisItchinessLazy EyeMacular DegenerationOccasional drynessRetinal DetachmentSunlight SensitivityTearingTrouble seeing at nightUncomfortable 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

MonthDayYear
CURRENT MEDICATIONS (Rx or Over the Counter)
Allergies to medications?

YesNo
If so, what medications?
Have you had any surgeries?

YesNo
Do you use cigarettes/tobacco, alcohol, or other substances?

YesNo
Have you ever been diagnosed or treated for the following health problems?
Allergies

YesNo
Arthritis

YesNo
Blood/Lymph

YesNo
Bronchitis

YesNo
Cancer

YesNo
Cholesterol

YesNo
Diabetes

YesNo
Digestive

YesNo
Ears/Nose/Throat

YesNo
Endocrine

YesNo
Eczema/Rashes

YesNo
Fatigue

YesNo
Fevers

YesNo
Genitourinary

YesNo
High Blood Pressure

YesNo
Integumentary (Skin)

YesNo
Kidney

YesNo
Muscle/Bone

YesNo
Neurological

YesNo
Psychological

YesNo
Respiratory

YesNo
Sinus

YesNo
Throat Infections

YesNo
Thyroid

YesNo
Unusual weight losses/gains

YesNo
Patient Eye History
Date of Last Eye Exam

MonthDayYear
Last Eye Exam Performed by whom?
Have you ever tried contact lenses?

YesNo
Do you currently wear contact lenses?

YesNo
If so, what kind?
Solutions used?
Are you satisfied with the vision and comfort of your contact lenses?

YesNo
Would you prefer clear contact lenses or colored contact lenses?

YesNo
If you wear bifocals, do the lines or head tilting bother you?

YesNo
Family Medical/Eye History (Select all that apply)

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

Yes, Mother's SideYes, Father's SideNo
Cataracts

Yes, Mother's SideYes, Father's SideNo
Corneal Problems

Yes, Mother's SideYes, Father's SideNo
Diabetes

Yes, Mother's SideYes, Father's SideNo
Glaucoma

Yes, Mother's SideYes, Father's SideNo
Heart Disease

Yes, Mother's SideYes, Father's SideNo
Lazy Eye

Yes, Mother's SideYes, Father's SideNo
Macular Degeneration

Yes, Mother's SideYes, Father's SideNo
Retinal Problems

Yes, Mother's SideYes, Father's SideNo
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)