Name: Advanced Vision Care of North Arlington
Address: 827 E Lamar Blvd, Arlington, TX, 76011, US
Telephone: 8172750655
Price range: $000 - $300

Medical History and Insurance
Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information
Name*
First Middle Last
Today's Date*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Number*
Please provide a telephone number, with area code, so we can contact you.
Cell Phone
Work Phone
Email Address*
Please provide your email address.
Employer
Occupation
Date of Birth*
MM slash DD slash YYYY
Social Security Number (last 4 digits only!)
Race/Ethnicity
Preferred Language
Gender*
- Female
- Male
Who may we thank for referring you to our office?
Date of Last Medical Exam
Name of Medical Doctor
Doctor's Phone Number
Date of Last Eye Exam
Current Height
Current Weight
Spouse or Guardian (If Applicable)
Medical History
Do you have any allergies to medications?
- No
- Yes
If Yes, list medication(s) and reaction below:
List any medications you take including oral contraceptives, aspirin, OTC medicines, etc.:*
Include Name of Medication, Dosage, Frequency Taken
List all major injuries, surgeries and/or hospitalizations you have had:
Check any of the following that you have had:
- Crossed Eyes
- Lazy Eye
- Drooping Eyelid
- Prominent Eyes
- Cataracts
- Glaucoma
- Iritis/Uveitis
- Macular Degeneration
- Retinal Disease of Detachment
- Eye Infections
- Eye Injury
- Corneal Problems
- Other Eye Disorders
If Other Eye Disorders, please explain:
Are you pregnant or nursing?
- No
- Yes
Do you wear glasses?
- No
- Yes
If Yes, how old is your present pair of lenses?
Do you wear contact lenses?
- No
- Yes
If Yes, how old is your present pair of lenses?
Type of Contact Lenses:
- Rigid
- Soft
- Extended Wear
- Other
Are they comfortable?
- No
- Yes
Family History
Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.
Disease/Condition
- Blindness
- Cataract
- Crossed Eyes
- Glaucoma
- Macular Degeneration
- Retinal Detachment or Disease
- Arthritis
- Cancer
- Diabetes
- Heart Disease
- High Blood Pressure
- Kidney Disease
- Lupus
- Thyroid Disease
- Other
If Other, please explain:
If Yes to any of the above, please explain:
Social History
This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.
I prefer to discuss my Social History information directly with my doctor.
- Yes
Do you drive?
- No
- Yes
If Yes, do you have visual difficulty when driving?
- No
- Yes
If Yes, please describe:
Do you use tobacco products?
- No
- Yes
If Yes, list type/amount/how long:
Do you drink alcohol?
- No
- Yes
If Yes, list type/amount/how long:
Do you use illegal drugs?
- No
- Yes
If Yes, list type/amount/how long:
Have you ever been exposed to or infected with:
- Gonorrhea
- Hepatitis
- HIV
- Syphillis
REVIEW OF SYSTEMS
Do you currently or have you ever had any problems in the following areas?
Constitutional
Fever, Weight Loss/Gain
- No
- Yes
Integumentary (Skin)
- No
- Yes
Neurological
Headaches
- No
- Yes
Migraines
- No
- Yes
Seizures
- No
- Yes
Eyes
Loss of Vision
- No
- Yes
Blurred Vision
- No
- Yes
Distorted Vision/Halos
- No
- Yes
Loss of Side Vision
- No
- Yes
Double Vision
- No
- Yes
Dryness
- No
- Yes
Mucous Discharge
- No
- Yes
Redness
- No
- Yes
Sandy or Gritty Feeling
- No
- Yes
Itching
- No
- Yes
Burning
- No
- Yes
Foreign Body Sensation
- No
- Yes
Excess Tearing/Watering
- No
- Yes
Glare/Light Sensitivity
- No
- Yes
Eye Pain or Soreness
- No
- Yes
Chronic Infection, Eye or Lid
- No
- Yes
Sties or Chalazion
- No
- Yes
Flashes/Floaters in Vision
- No
- Yes
Tired Eyes
- No
- Yes
Endocrine
Thyroid/Other Glands
- No
- Yes
Elevated Cholesterol
- No
- Yes
Cancer
- No
- Yes
Ears, Nose, Mouth, Throat
Sinus Congestion
- No
- Yes
Runny Nose
- No
- Yes
Post-Nasal Drip
- No
- Yes
Chronic Cough
- No
- Yes
Dry Thoat/Mouth
- No
- Yes
Allergies/Hay Fever
- No
- Yes
Respiratory
Asthma
- No
- Yes
Chronic Bronchitis
- No
- Yes
Emphysema
- No
- Yes
Vascular/Cardiovascular
Diabetes
- No
- Yes
Heart Pain
- No
- Yes
High Blood Pressure
- No
- Yes
Vascular Disease
- No
- Yes
Gastrointestinal
Diarrhea
- No
- Yes
Constipation
- No
- Yes
Genitourinary
Genitals/Kidney/Bladder
- No
- Yes
Bones/Joints/Muscles
Rheumatoid Arthritis
- No
- Yes
Muscle Pain
- No
- Yes
Joint Pain
- No
- Yes
Lymphatic/Hematologic
Anemia
- No
- Yes
Bleeding Problems
- No
- Yes
Allergic/Immunologic
Allergic/Immunologic
- No
- Yes
Psychiatric
Psychiatric
- No
- Yes
If you answered Yes to any of the above or have a condition not listed, please explain and list medications:
Patient Signature
Date
MM slash DD slash YYYY
Insurance
Patient Name
First Last
Patient Date of Birth
MM slash DD slash YYYY
Insurance Primary Name
Primary Social Security Number
Name of Vision Insurance
Vision Insurance ID Number
Name of Medical Insurance
Medical Insurance ID Number
Medical Insurance Group Number
Medical Insurance Phone Number
HIPAA Acknowledgment
Advanced Vision Care of North Arlington,
PA 827 E. Lamar Blvd. Arlington, TX 76011
817-2754-0655
The law requires that Advanced Vision Care make every effort to inform you of your rights related to your personal health information. by my signing below. I acknowledge that:
Please check off
I have read or had explained to me prior to any services offered Advanced Vision Care Notice of Privacy Practice and agree to continue my care with Advanced Vision Care under said terms.
Please check off
I have read or had explained to me prior to any services offered Advanced Visioncare's Notice of Privacy Practice and do not wish to continue my care with Advanced Vision Care under said terms.
Please check off
The Notice of Privacy Practice could not be read due to the emergent nature of the care or other reason described as:
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
Patient Name
First Last
Date
MM slash DD slash YYYY
Read & Decide
- By making a check mark or writing your initials, it gives us permission to email you from our email account and Solutionreach, our recall system.
Please list any other people allowed to speak on behalf of you or granted permission to pick up your contact lense, glasses, etc...
OPTOMAP Agreement
Advanced VisionCare offers a state-of-the-art digital scanning technology that allows us to see the inside of your eye without the use of dilation drops. The OPTOMAP allows us to evaluate your retina for problems such as macular degeneration, retinal holes, retinal detachments, hypertension and diabetic retinopathy. The scanning system is completely safe for kids and adults and allows you the opportunity to see the inside of your eye just as the doctor sees it.
DILATED EXAM
1. Blurred vision for 4-6 hours
2. Light sensitivity for 4-6 hours
3. Longer office visit to wait for drops to take effect
4. No permanent record of your retina
5. Only the doctor can see the retina
OPTOMAP EXAM
1. No blurred vision
2. No light sensitivity
3. Map takes less that 2 minutes to process
4. Permanent digital image that can be reviewed/compared each year
5. You can see your retina
EARLY DETECTION IS CRUCIAL
Our doctors recommend that all patients have a thorough examination of their retina every year. Without the OPTOMAP or dilated examination, the doctor cannot fully assess the health of your eye. There is an additional fee of $32.00 for the OPTOMAP. In most cases, the procedure is not covered by insurance. Dilation may still be required in rare instances.
Your Name & Surname
First Last
Please Select
- I elect to have a digital photo of my retina ($32.00)
- I prefer a dilated exam of my retina (no additional fee)
Permission to File Form
Patient Name
First Last
Permission for Filing Insurance
Your signature below gives Advanced VisionCare of North Arlington the permission to file an insurance claim on your behalf.
Signature of Patient or Patient's Representative
Date
MM slash DD slash YYYY
Patients with Vision and/or Medical Insurance
In the event that your insurance states that you are not eligible for coverage at the time of service, or determines that you are eligible for a reduced level of coverage, by signing this statement, you hereby agree to be financially responsible for any and all charges incurred by you that are not paid by your insurance provider.
Signature of Patient or Patient's Representative
Date
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Online Forms

Medical History and Insurance

Patient Information

Medical History

Family History

Social History

REVIEW OF SYSTEMS

Constitutional

Neurological

Eyes

Endocrine

Ears, Nose, Mouth, Throat

Respiratory

Vascular/Cardiovascular

Gastrointestinal

Genitourinary

Bones/Joints/Muscles

Lymphatic/Hematologic

Allergic/Immunologic

Psychiatric

Insurance

HIPAA Acknowledgment

OPTOMAP Agreement

Permission to File Form

Permission for Filing Insurance

Patients with Vision and/or Medical Insurance

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Advanced Vision Care of North Arlington