Online Forms

Gender

Marital Status

Last 4 of SS#

Name of Spouse/Parent/Guardian

Home Address

Work Address

Have other members of your family received care at our office?

Whom may we thank for referring you to us?

Responsible Party

Insurance Information

Please present your insurance card and forms to the receptionist.

Do you have vision or medical insurance that may cover todays visit?

Name of Policy Holder

Relationship to Patient

Ocular and Systemic Health Information

Date of Last Eye Exam

Reason for todays visit?

Do you currently wear glasses?

Do you currently wear contacts?

General Care Physician's Name

Date of Last Physical

Do you have problems with any of the following systems?
^{If yes, please check that box.}

Drug allergies?

Seasonal allergies?

Do you currently take any Medications?
^{If Yes, Please fill out the List Medication/s Field.}

List Your Medication/s

Do you or anyone in your immediate family have a history of the following:

Flashes of Light

Do you or have you experienced any of the following (use Other for unlisted problems):

Eye Infection/Disease

Other

Please indicate any of the following activities in which you use your eyes:

Please indicate interest in any of the following:

Authorization/Payment

In striving to provide the best, most comprehensive eye care and optical services at a reasonable cost, we appreciate your paying in full at the time of your visit. All insurance deductibles and co-pays are to be paid at the time of your visit.

​​​​​​​I authorize Smoke Vision Care to release any information including the diagnosis and records of any treatment or examination rendered to me or my dependent to third party payers and/or health care practitioners. I authorize and request my insurance company to pay directly to Smoke Vision Care insurance benefits otherwise payable to me. I understand phone verification and authorization does not guarantee coverage or the covered amount verbally quoted by the insurance company. I understand that although Smoke Vision Care does it’s best to help be estimate what these benefits will be, actual reimbursement amount may differ. In the event of denial of payment or non-coverage for my visit by my insurance company, I agree to be responsible for payment of all services rendered.

Signature *

Date

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