Convenient Online Form Patient Medical and Information Patient Information Step 1 of 9 11% Welcome to our Office!www.ThomasEyeCenter.comThe online Patient Medical Information form is a convenient way for our patients to update contact information, medical history and policy notices at Thomas Eye Center. This online form is divided into nine short sections. After completing the form online, Thomas Eye Center will have a printout available when you visit our office so that you may review or update any information at that time as well. You will also have a chance to review your entries before submitting the form. You may click on the “previous” or "next" buttons at anytime to move to and edit any section.Name: Today's Date: Address: City: State: Zip: Date of Birth: Month Day Year Sex: Male Female Last four digits of Social Security Number Email Address: Work Phone:Home Phone:Cell Phone:Preferred Method of Contact: Marital Status:(check one) Single Married Other If Other, please state Employment/School Status:(check one) Employed Full Time Student Full Time Employed Part Time Student Part Time Not Employed Retired Employer/School: Position/Major or Grade: Employer Address & Phone: Family Medical/ Eye HistoryIs there a family medical history of any of the following? (check all that apply and list relationship to patient) Amblyopia/Lazy Eye Blindness Cataracts Corneal Abrasion Diabetes Glaucoma Heart Disease High Blood Pressure Macular Degeneration Retinal Problems Relationship to Patient - Amblyopia/Lazy Eye* Relationship to Patient - Blindness* Relationship to Patient - Cataracts* Relationship to Patient - Corneal Abrasion* Relationship to Patient - Diabetes* Relationship to Patient - Glaucoma* Relationship to Patient - Heart Disease* Relationship to Patient - High Blood Pressure* Relationship to Patient - Macular Degeneration* Relationship to Patient - Retinal Problems* Patient Medical HistoryName of Primary Physician: Physician City & State: Current Medications(List name and dosage, including Rx and OTC)Allergies to Medications/Environmental: Have you ever been diagnosed or treated for the following? Allergies Asthmas Arthritis Cancer Cholesterol Diabetes Heart Disease High Blood Pressure Kidney Nerves Thyroid Gastrointestinal Mental Other If Other, please state Surgeries/Operations (include year): Patient Eye HistoryDate and Location of Last Eye Exam: Dilated Yes No Do you currently wear contacts? Yes No Interested Type of contacts worn & solution used: Have you ever been diagnosed or treated for the following? Cataracts Corneal Abrasions Eye Infection Eye Injury Glaucoma Iritis/Uvetis Lazy Eye Macular Degeneration Retinal Detachment Other If Other, please state: Do you currently experience any of the following? Blurry Vision Burning Tearing Headaches Flashes of light Dryness Floater/spots Grittiness Itchiness Double Vision Sunlight sensitivity Crossed eye/eye turn Trouble seeing at night Uncomfortable glasses Other If Other, please state: Receipt of Privacy PracticiesI acknowledge that I have been offered or upon request I can obtain a copy of the Notice of Privacy Practices for this office. You may also click here to view and download our Notice of Privacy Practices (PDF).Initials:* Acknowledgment of Professional Contact Lens ServiceIn addition to the contact lens exam cost, there could be an additional design, fit, and follow-up charge that covers training and up to two additional visits with the doctor. For exact pricing, please speak to one of our staff members.Initials:Please initial only if you are having a contact lens exam. Consent for DisclosureI authorize Thomas Eye Center to disclose information to the individual(s) listed below by discussion: in my presence and also when I am not physically present; including disclosure by telephone, fax, email or mail any information related to my medical care, account information, making of appointments, prescription concerns, etc. I understand that this consent is in effect until revoked by me with written notice to the practice.Name: First Last Relationship: Phone:Name: First Last Relationship: Phone: Patient Financial Responsibility PolicyPayment is required at the time that services are rendered. This includes coinsurances, copayments, and deductibles for participating insurance companies. Thomas Eye Center accepts cash, personal checks (in state only), Visa, MasterCard, Discover, American Express, and Care Credit. There is a $30.00 service charge for each returned check. Dr. Thomas performs a comprehensive eye examination that checks for all eye diseases, structures of the eye and includes for “routine vision” as all exams performed are medical in nature. A charge of $50.00 will be incurred for appointments missed or cancelled without a 24 hour notice. Excessive abuse of missed appointments may result in discharge from the practice. Payment in full is required for all materials (glasses and contact lenses) before they are ordered. Once payment on materials is made your order is immediately placed and the manufacturing of your eyeglass lenses begins. Being that eyeglass lenses are created specifically for your eyes there are no returns or refunds on your eyeglass lenses once they have been ordered. I, the undersigned, have read and understood this information authorize the release of medical and other necessary information to my insurance company to process claims for services rendered. I hereby authorize my insurance company to distribute payment of my coverage directly to Thomas Eye Center. I understand that I am responsible for all charges regardless of my insurance benefits. I authorize the use of this signature on insurance submissions. I certify that I am the patient or parent/guardian authorized to furnish the information requested.Date: Patient's Name:* Patient's Signature:Use your mouse or touchscreen to add your signature.Parent / Guardian: (if patient is under 18 years old) Be sure to click SUBMIT at the bottom of the page. Please confirm all your details before submitting the online patient information form. If you find an error or would like to change an entry, click the "Previous" button to return to previous sections of the form. {all_fields}NameThis field is for validation purposes and should be left unchanged.