Step 1 of 6 16% Your Name* Your Email Address* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Your Phone Number*Your Gender* Male Female Your Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Race Your Current Employer* Your Occupation* Spouse/Guardian/Parent Name* What is their relation to you?* Spouse Guardian Parent Reason for Current Exam*Routine Eye ExamContact Lens UpdateBlurry Vision (at far)Blurry Vision (at near)Glasses Broken/ScratchedEye Health ProblemEye Health EmergencyOtherPlease Tell Us MoreDate of Last ExamMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Location of Last Exam Patient HistoryHave you experienced any of the following recently (check all that apply)? Dry or Watery Eyes Itchy or Swollen Eyes Discharge in the Morning Around Eyelashes Eye Infections or Red Eyes Eye Injuries or Surgeries Floaters or Flashing Lights Curtain Loss of Vision or Waviness of Vision Color Vision Changes Double Vision Do you wear contacts?* Yes No Are you interested in contacts for the first time, or interested in returning to them?* Yes No Unique Visual NeedsHow many hours a day do you spend on a computer?Please enter a number from 1 to 24.How many hours a day do you spend driving?Please enter a number from 1 to 24.Do you have any hobbies?Do you own a pair of 100% UV sunglasses? Yes No Are there times that you'd rather not wear eyewear? Yes No Do you spend a lot of time outdoors? Yes No Do you own more than one pair of current prescription eyewear? Yes No Does your profession or lifestyle require you to wear protective eyewear? Yes No Any additional info you'd like to share? Medical HistoryPrimary Care Physician Primary Care Physician Phone NumberDate of Last VisitMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Physician Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Have you had any of the following (check all that apply)?* Eye Surgery Lazy Eye/Amblyopia Vision Therapy/Patching Cataracts Glaucoma Macular Degeneration Retinal Detachment High Blood Pressure Heart Disease Diabetes Thyroid None of These Has any of your family had any of the following (check all that apply)? Eye Surgery Lazy Eye/Amblyopia Vision Therapy/Patching Cataracts Glaucoma Macular Degeneration Retinal Detachment High Blood Pressure Heart Disease Diabetes Thyroid None of These Do you have any of the following (check all that apply)?* Ear/Nose/Throat: ear infection, sinus problem, sore throat Respiratory: asthma, emphysema, chronic bronchitis Neurological: numbness migraines, seizures, weakness Heart: chest pain, irregular heart beat Musculoskeletal: arthritis, joint pain, swollen joints Skin: rosacea, eczema Lymphatic / Hematologic: anemia, bleeding problems Psychiatric: depression, anxiety, hyperactivity Gastrointestinal / Stomach Disease Kidney / Urinary Tract Disease Cancer None of These Do you have any environmental allergies?Do you have any drug allergies?Are you taking any medications (including over-the-counter)?Are you currently pregnant?* Yes No If dilation is needed, can we dilate your eyes on your next exam date?* Yes No Vision InsuranceYour Vision InsuranceRegence BlueShieldAetnaFirst ChoicePacifiCareUniform MedicalLifewiseHMAMedicareVSPEyemedDSHSCommunity Health PlanMolinaSpecteraUnited Health CareCigna (PPO and Open Access)OtherPlease Specify Primary Insurance Provider Social Security or ID Number Subscriber Name Group Number Subscriber Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920We do not directly bill any other insurance. Insurance coverage and verification of coverage for reimbursement is the sole responsibility of the patient. Professional fees are non-refundable. Personal Referral Name Additional InfoI hereby authorize COMFORT VISION to release any medical or other information necessary in order to process insurance claims billed on my behalf. I also authorize payment directly to the doctor for any benefits available under my insurance plan. I understand that I am financially responsible for any fees that the insurance companies do no pay including co-payments, deductibles and non-covered services. Our office does not accept responsibility for collecting or negotiating disputed insurance claims past 60 days. Regardless of your coverage you are responsible for all incurred charges. Non- participating plans may reimburse you directly. A standard billing service charge of $2.00 will be posted on all accounts 30 days or older. A bank service fee of $40 will be charged on any checks returned for insufficient funds. Accounts 90 days old will be submitted to a collection agency. Note to all contact lens patients- contact lens exams, fittings, classes, and evaluations are not covered benefit under MOST insurance plans. If you chose to be examined for contacts and/or need to be fit with contact lenses, you will be responsible for the professional services due on the day of your exam. ALL contact lens exams and follow ups must be completed within 60 days of initial exam. Monitoring your eye health is the doctor's responsibility, therefore a ONE year expiration for the contact lens prescription may be deemed medically necessary to prevent eye damage and encourage correct contact lens compliance. By pressing submit, you agree with the statement above and confirm that all of the information above is correct.CommentsThis field is for validation purposes and should be left unchanged.
