- **ALL PATIENTS ARE REQUIRED TO SUBMIT A PATIENT REGISTRATION FORM AHEAD OF THEIR APPOINTMENT. INCOMPLETE FORMS WILL DELAY YOUR CHECK IN PROCESS**
Please complete the information below and submit the form online. If you are unable to submit this form online, you must call the office so that we can pre-register you over the phone.
This form contains confidential information and is delivered to your doctor through a secure Internet connection. NEW PATIENT REGISTRATION FORM:
This registration should be used only for NEW patients who have NOT previously been seen by Dr. Janot's Vision Source Office in Sulphur. If you are a returning patient to our office, please use the Registration Form for RETURNING Patients.
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Please provide a cell number, with area code, so we can contact you.
Personal Information
MM slash DD slash YYYY
*Note: This is required for us to file any medical insurance which may cover eye issues. Note that we do not file on any vision plans.
Please provide your marital status if you selected "other" above.
You selected "Other" for your employment status, please describe your employment status here.
Please let us know if there is someone we may thank for referring you to our office.
Someone to whom you give us permission to contact in an emergency or to whom we may share your personal health information.
Do you (this patient) have any special needs? If so, please select all that apply.
You selected "Other" for Special Needs, please describe the patient's needs here.
Eye History
Please tell us approximately when (if ever) & where (or Doctor's name) was your last eye examination. Feel free to add any details of that encounter.
Please select all that apply.
Please select all applicable eye conditions/history you have had:
Please select all applicable you have had:
Please list any eye conditions that run in your family (blood relatives) such as Glaucoma, Macular degeneration, diabetic eye disease, eye cancers, retinal disorders, etc.
Glasses History
Please tell us what other kinds of prescription eyeglasses you have.
Contact Lens History
If you know your current contact lens brand and prescription, please list that here. (information may be obtained from the boxes which the contact lenses come in)
Medical History
Please select any procedures / surgeries which apply to you:
If you take no medications, supplements, vitamins, or OTC products on a regular basis, please put NONE. If you have a list which you would like to upload and send it instead, you may do so below.
SPECIAL INSTRUCTIONS:
PLEASE BRING TO YOUR APPOINTMENT ANY AND ALL OVER-THE-COUNTER AND PRESCRIPTION EYE DROPS, SALVES, OR PRODUCTS YOU USE IN OR AROUND YOUR EYES.
If you have a current list of your medications and are able to upload it, you may do so here and not have to list them all above.
Your medical eye record must contain an up to date listing of your medications, along with strength and dosing schedules. Many medications affect the eye as well. We can often obtain an accurate list by using your Pharmacy Benefits Manager (PBM). Do you grant Dr. Robert Janot permission to request prescription history information on your behalf for the purpose of providing direct health care services?
Note that if you decline to grant permission, it is mandatory that you provide an accurate list of medications, including strength, dosing and prescriber.
About Eye & Vision Insurance
PLEASE NOTE: There are 2 types of "Eye" Insurance, Medical Insurance (through your major medical provider) and Vision Plans / Insurance (always a separate part of your health insurance OR, more commonly, a separate plan given by your employer). You may have one, both, or neither of these coverages. Here's a description for each:
*MEDICAL: Covers "non routine care" such as eye examinations for Diabetes, Cataracts, Glaucoma, Macular Degeneration, Dry Eyes, Allergies, Infections, Red Eyes, etc. WE ACCEPT & FILE MOST MEDICAL INSURANCES.
*VISION: These plans (often called insurance) pay SOME AMOUNTS toward Glassses, Contact Lenses, and Routine Eye Exams. We are an OUT OF network provider for all vision plans. You may be able to file for vision benefits after the fact, but we do not file those from our office.
PLEASE BRING YOUR MEDICAL INSURANCE CARD(s) WITH YOU TO YOUR APPOINTMENT AND, IF YOU CAN, PLEASE UPLOAD THEM BELOW.
Medical Insurance Information
Please indicate which, if any, major medical (health) insurances you have.
This is an optional field, yet if you are able to upload copies of your MEDICAL insurance card(s) it will greatly expedite your check in process. Be sure to include both the front and back of each card you upload. REMINDER: We do not accept any vision plan benefits that you may have.
Please let us know if there are any other issues, of which we should be aware, prior to your visit.
Privacy Policy
Please kindly provide 24h notice if you must cancel for any reason. Non cancelled appointments will incur a $35 fee.
This field is for validation purposes and should be left unchanged.
