**DUE TO THE COVID-19 PANDEMIC, ALL PATIENTS ARE REQUIRED TO SUBMIT A PATIENT REGISTRATION FORM AHEAD OF THEIR APPOINTMENT. INCOMPLETE FORMS WILL DELAY YOUR CHECK IN PROCESS** 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.
Name*
Prefix
Mr. Mrs. Miss Ms. Dr. Prof. Rev.
First
Last
Suffix
Address*
Phone Number* Please provide a telephone number, with area code, so we can contact you.
Daytime Phone
Cell Phone
Email Address
Personal Information Gender* Date of Birth*
MM slash DD slash YYYY
Social Security Number *Note: This is required for us to file any insurance, vision or medical, on your behalf.
Marital Status Select Marital Status > Child Divorced Legally Separated Married Single Widowed Other
Marital Status - Other Please provide your marital status if you selected "other" above.
Employment Status* Select Employment Status > Disabled Employed Full-Time Employed Part-Time Full-Time Student Not a Student Not Employed On Active Military Duty Part-Time Student Retired Self-Employed Unknown Other
Employment Status - Other You selected "Other" for your employment status, please describe your employment status here.
Employer
Occupation
How were you referred to our office? Select Referral Type > Care Credit Website Family Are Patients Newspaper Online Search Patient Referral Phone Book Professional Referral Return Patient Walk In Patient Website Other
Referring Person Please let us know if there is someone we may thank for referring you to our office.
Preferred Language* Select Preferred Language > English Spanish Decline to specify French Japanese
Race* Select Race > American Indian or Alaska Native Asian Black or African American Decline to specify European Hispanic / Latino Native Hawaiian or Other Pacific Islander White
Ethnicity* Select Ethnicity > Decline to specify Hispanic or Latino Native Hawaiian or Other Pacific Islander Not Hispanic or Latino
Communication Preference* Select Communication Preference > Call: Cell Phone Call: Home Phone (land line) Call: Work Phone e-mail Text Messaging
Emergency Contact* Someone to whom you give us permission to contact in an emergency or to whom we may share your personal health information.
Emergency Contact's Phone*
Relationship* Select Emergency Contact's Relation > Spouse Child Parent Grandparent Caregiver/Guardian Sibling Friend Daughter/Son In Law Other
Special Needs* Do you (this patient) have any special needs? If so, please select all that apply.
No Special Needs Wheelchair (patient can get into examination chair) Wheelchair (patient cannot get into examination chair) Hard of Hearing Hyperactive Autism Cerebral Palsy Mentally Challenged Social Anxiety Other
Special Needs - Other You selected "Other" for Special Needs, please describe the patient's needs here.
Eye History Last Eye Exam* 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.
What is the main reason for your visit today?*
Ocular History (Eye Conditions)* Please select all applicable eye conditions / history you have had
NONE Allergic Conjunctivitis (Eye Allergies) Blepharitis Cataracts Corneal Dystrophy Diabetic Retinopathy Dry Eyes Glaucoma Macular Degeneration Ocular Migraine / Migraine Retinal Tear Strabismus (Eye Turn / Crossed Eyes) Floaters Amblyopia (Lazy or Weak Eye) Chronic Infection of Eye or Lid (Styes, etc) Conjunctivitis (Pink Eyes) Corneal Foreign Bodies (metal in eyes, etc) Double Vision Drooping Eyelid Excess Tearing/Watering Eye Injuries Iritis / Uveitis Melanoma (Cancer of Eye) Retinal Detachment Retinal Disease Retinal Hole Other
You indicated "Other" eye condition(s) you may have had. Please tell us here.
Ocular Surgery* NONE Blepharoplasty (Eyelid Lift, Age Related) Cataract Surgery Corneal Transplant Eye Muscle Surgery Eye Injections (Intravitreal Injections) LASIK LASER Surgery for Glaucoma (LPI, SLT, etc) PRK (Photorefractive Keratectomy) Ptosis Repair (to repair lid droop, usually children) Punctal Plugs Strabismus Surgery (for crossed / turned eye) Retinal Laser (for tears, holes, etc) Trabeculectomy (for glaucoma) Tube Shunt (for glaucoma) Yag Capsulotomy (to clear film after cataract surgery) Corneal Surgeries (cross linking, etc) Foreign Body Removal LASER Surgery for Diabetes LASER Surgery for Macular Degeneration RK (Radial Keratotomy) Tear Duct Surgery Vitrectomy Other
You indicated "Other" eye surgeries you may have had. Please tell us here.
Family Eye History 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 Do you currently wear glasses, even part time?* What prescription eyeglasses do you currently have? Other glasses: Please tell us what other kinds of prescription eyeglasses you have.
How do you use / wear your glasses? I wear prescription glasses full time I wear over the counter reading glasses I wear prescription glasses mostly for school/reading/computer I wear prescription glasses only for driving/distance Other
Please select all that apply Do you plan to change / update / purchase new glasses at this visit?* Contact Lens History Do you currently wear contact lenses, even part time?* What brand of contact lenses do you wear? 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)
How old are your current lenses?
How is your vision in your contact lenses?* With contacts, my vision is good, no change noted With contacts, distance is blurry With contacts, near vision is blurry With contacts, computer vision is blurry Other
How comfortable are your contact lenses?* Extremely comfortable, no issues Fairly comfortable, mild irritations Not very comfortable, would like improvement Contacts seem to be dry, especially end of day Other
How often do you replace or dispose of your contact lenses?* Daily (single use lenses) Every 2-3 days Every week Every 2 weeks Every month Every 2 months Every 3-4 months Every 6 months Yearly, or as necessary (gas permeables, sclerals) Other
With what brand of solution do you clean & store your lenses?* Opti Free Pure Moist Opti Free Replenish BioTrue Clear Care (peroxide based) Equate or other store brand I'm not sure which solution I use I use no solution, change my lenses daily Other solution not listed here
What is your typical contact lens wearing schedule?* Every day, most/all waking hours Every day, sleep in lenses 1-3 nights Every day, sleep in lenses 3-7 nights Every day, sleep in lenses 1-2 weeks Every day, sleep in lenses 2-4 weeks Every day, sleep in lenses 4-6 weeks Every day, sleep in lenses 6-8 weeks Every day, sleep in lenses 2-3 months Every day, sleep in lenses 3-6 months Part time wear of lenses, 1-2 days / wk Part time wear of lenses, 2-4 days / wk Part time wear of lenses, social/recreational only Other schedule, not listed above
Please select all that apply* Medical History Who is your primary care physician?*
Do you smoke?* Do you smoke? > Current Everyday Smoker Current Someday (Occasional) Tobacco User Current Someday (Occasional) Cigarette Smoker Former Smoker Never Smoker Cigar Smoker
Please select all medical conditions which apply to you* NONE Anxiety Arthritis Asthma Atrial Fibrillation (Irregular Heartbeat) Bone Marrow Transplantation BPH (enlarged prostate gland) Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD (Acid Reflux/Heartburn) Hearing Loss Hepatitis Hypertension (High Blood Pressure) HIV / AIDS Hypercholesterolemia (high cholesterol) Hyperthyroidism (Elevated Thyroid Levels) Hypothyroidism (Low Thyroid Levels) Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke ADHD, ADD (attention deficit disorders), Autism Allergies (hay fever, environmental, seasonal allergies) Anal Cancer Anemia / bleeding or clotting disorders Angina (chest pain) Artificial Heart Valve Blocked carotid arteries Blood thinners Brain Cancer / Tumor(s) Bronchitis (Chronic) Corona Virus ED (Erectile Dysfunction) Excema Emphysema Gout Heart Attack Joint Pain Joint Problems (neck / disc / spine / shoulder / knee) Mental illness, bipolar, manic depressive, schizophrenia (emotional disorders) Migraine Headaches (diagnosed) Osteoporosis / Osteopenia Ovarian Cancer Pacemaker Psoriasis Rosacea Seizures, epilepsy, multiple sclerosis Skin Cancer Testicular Cancer Urinary Urgency (Incontinence) Other
Hospital or Outpatient Surgeries / Procedures* Please select any procedures / surgeries which apply to you.
NONE Appendix (Appendectomy) Bladder (Cystectomy) Breast : Breast Biopsy Breast : Lumpectomy (Both Breasts) Breast : Lumpectomy (Left Breast) Breast : Lumpectomy (Right Breast) Breast : Mastectomy (Both Breasts) Breast : Mastectomy (Left Breast) Breast : Mastectomy (Right Breast) Colon (Colectomy) : Colon Cancer Resection Colon (Colectomy) : Diverticulitis Colon (Colectomy) : Inflammatory Bowel Disease Colon: Colostomy Gallbladder (Cholecystectomy) Heart : Biological Valve Replacement Heart : Coronary Artery Bypass Surgery Heart : Heart Transplant Heart : Mechanical Valve Replacement Joint Replacement : Hip (Both) Joint Replacement : Hip (Left) Joint Replacement : Hip (Right) Joint Replacement : Knee (Both) Joint Replacement : Knee (Left) Joint Replacement : Knee (Right) Kidney : Kidney Biopsy Kidney : Kidney Stone Removal Kidney : Kidney Transplant Kidney : Nephrectomy Liver: Hepatectomy Liver: Liver Transplant Liver: Shunt Ovaries (Oophorectomy) : Endometriosis Ovaries (Oophorectomy) : Ovarian Cancer Ovaries (Oophorectomy) : Ovarian Cyst Ovaries: Tubal Ligation Pancreas: Pancreatectomy Prostate : Prostate Biopsy Prostate : Prostatectomy Rectum: Low Anterior Resection Skin : Basal Cell Carcinoma Skin : Melanoma Skin : Skin Biopsy Skin : Squamous Cell Carcinoma Spleen (Splenectomy) Testicles (Orchiectomy) Uterus (Hysterectomy) : Fibroids Uterus (Hysterectomy) : Uterine Cancer Uterus (Hysterectomy): Cervical Cancer Brain Surgery Other
Please list all prescription and over-the-counter medications you take and for what conditions* 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.
Upload Medication List 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.
Permission to Verify Medications / Dosages* 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?
Please list all drug allergies you have
COVID-19 Questions (Required) Have you had COVID-19?* When did you have COVID-19?
Have you had a COVID-19 vaccination?* When did you have your COVID-19 vaccination?
What type of vaccine did you receive? 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 Insurance Information Medical Insurance* Please indicate which, if any, major medical (health) insurances you have.
Blue Cross / Blue Shield United Healthcare Aetna Cigna Humana Medicare I have no major medical coverage Other
Primary Policy Holder (Medical Insurance)
Last 4 Digits of Primary Policy Holder's Social Security Number
Group ID Number (Medical Insurance)
Member ID Number (Medical Insurance)
Vision Plan (Insurance) Information Vision Plan* Please indicate which, if any, vision plan you have.
I have no vision plan Aetna Vision Blue View Cigna Vision Davis Vision EyeMed Spectera Superior VSP Other
Primary Policy Holder (Vision Plan)
Last 4 Digits of Primary Policy Holder's Social Security Number
Primary Policy Holder's Date of Birth
ID Number (Vision Plan)
Upload Insurance Cards This is an optional field, yet if you are able to upload copies of your 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.
Other Comments Please let us know if there are any other issues, of which we should be aware, prior to your visit.
Privacy Policy Information Health Protection* Cancellation fee Please kindly provide 24h notice if you must cancel for any reason. Non cancelled appointments will incur a $35 fee.
Email This field is for validation purposes and should be left unchanged.
Dr. Janot's Vision Source Welcomes Dr. Nilupul Bulathsinhala!