RETURN Patient Registration Form **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** 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.RETURN PATIENT REGISTRATION FORM:This registration should be used only for RETURN patients who have previously been seen by Dr. Janot's Vision Source Office in Sulphur. If you are a NEW patient to our office, please use the Registration Form for NEW Patients.Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country 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 Phone Number*Please provide a telephone number, with area code, so we can contact you.Daytime PhoneCell PhoneEmail AddressPlease provide us your email address.Please Update Any Information, if changedMarital StatusSelect Marital Status >ChildDivorcedLegally SeparatedMarriedSingleWidowedOtherMarital Status - OtherPlease provide your marital status, if not listed above.Employment StatusSelect Employment Status >DisabledEmployed Full-TimeEmployed Part-TimeFull-Time StudentNot a StudentNot EmployedOn Active Military DutyPart-Time StudentRetiredSelf-EmployedUnknownOtherEmployment Status - OtherPlease provide your employment status.EmployerOccupationEmergency ContactSomeone to whom you give us permission to contact in an emergency or to whom we may share your personal health information.Emergency Contact's PhoneRelationshipSelect Emergency Contact's Relation >SpouseChildParentGrandparentCaregiver/GuardianSiblingFriendDaughter/Son In LawOtherLast Eye Exam (if done elsewhere)ONLY IF YOUR LAST EYE EXAMINATION WAS DONE ELSEWHERE, please tell us approximately when (if ever) & where (or Doctor's name). Feel free to add any details of that encounter. Reason(s) for Visit / Chief Complaint(s)What is the main reason for your visit today?*Please describe any NEW eye conditions you are having since we last saw you?Vision / Glasses Information & UpdatesDo you currently have or wear eyeglasses?*YESNOCurrent Glasses Being WornIf the glasses you are now wearing are NOT the ones you last purchased here, please tell us when & where you got them.How is your vision in your current glasses?*Do you have an extra / spare / older pair of glasses which can be used in an emergency?*NOYESWould you like more information on any of the following? (Please indicate all that apply) Prescription computer glasses w blue light filter Prescription smart phone / tablet glasses w blue light filter Prescription sunglasses (may include polarization, mirror coatings, anti glare) Transitions self tinting lenses Update my eyeglass frames to a newer style Getting a spare or back up set of glasses Do you plan to change / update / purchase new glasses at this visit?* Yes No Not sure Any pain or irritation in or around your eye(s)?*NOYESIf so, please describe the pain / irritation:*Rate your level of pain / irritation:*On a scale of 1 to 10, with 10 being the worst pain, choose your pain / irritation level.12345678910Contact Lens Information & UpdatesDo you currently have or wear contact lenses?*YESNOCurrent Contacts Being WornIf you wear contact lenses that are NOT the ones you last purchased here, please tell us when & where you got them, and also the type (if you know)How old are your current contact lenses?How is your vision with your contact lenses?With contacts, my vision is good, no change notedWith contacts, distance is blurryWith contacts, near vision is blurryWith contacts, computer vision is blurryOtherHow comfortable are your contact lenses?Extremely comfortable, no issuesFairly comfortable, mild irritationsNot very comfortable, would like improvementContacts seem to be dry, especially end of dayOtherHow often do you replace or dispose of your contact lenses?Daily (single use lenses)Every 2-3 daysEvery weekEvery 2 weeksEvery monthEvery 2 monthsEvery 3-4 monthsEvery 6 monthsYearly, or as necessary (gas permeables, sclerals)OtherWith what brand of solution do you clean & store your lenses?Opti Free Pure MoistOpti Free ReplenishBioTrueClear Care (peroxide based)Equate or other store brandI'm not sure which solution I useNo solution, I change my lenses dailyUnique pH (gas permeable, scleral lenses)Boston Simplus (gas permeable lenses)Boston Original (gas permeable lenses)Boston Advance (gas permeable lenses)Other solution not listed hereWhat is your typical contact lens wearing schedule?Every day, most/all waking hoursEvery day, sleep in lenses 1-3 nightsEvery day, sleep in lenses 3-7 nightsEvery day, sleep in lenses 1-2 weeksEvery day, sleep in lenses 2-4 weeksEvery day, sleep in lenses 4-6 weeksEvery day, sleep in lenses 6-8 weeksEvery day, sleep in lenses 2-3 monthsEvery day, sleep in lenses 3-6 monthsPart time wear of lenses, 1-2 days / wkPart time wear of lenses, 2-4 days / wkPart time wear of lenses, social/recreational onlyOther schedule, not listed abovePlease select all that apply I am doing great with my current contacts, not anticipating a change I am interested in single use / daily contact lenses for health & convenience I am interested in contact lenses to enable me to see better up close & at my computer I am interested in self tinting contact lenses I am interested in changing or enhancing my eye color I am interested in refractive laser surgery Medical Information & UpdatesWho is your primary care physician?Do you smoke?*Do you smoke? >Current Everyday SmokerCurrent Someday (Occasional) Tobacco UserCurrent Someday (Occasional) Cigarette SmokerFormer SmokerNever SmokerCigar SmokerIF YOU ARE A DIABETIC, what was your most recent A1C (%) reading?IF YOU ARE A DIABETIC, what was your most recent home blood sugar reading?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? Note that if you decline to grant permission, it is mandatory that you provide an accurate list of medications, including strength, dosing and prescriber. YESNOPlease list any NEW medical conditions which have been developed since your last visit herePlease list any NEW prescription and over-the-counter medications since your last visit hereList any medication(s) that you have DISCONTINUED since your last visit hereUpload Medication ListIf you have a current list of your medications and are able to upload it, you may do so here. Drop files here or COVID-19 Questions (Required)Have you had COVID-19?*NOYESWhen did you have COVID-19?Have you had a COVID-19 vaccination?*NOYESWhen did you have your COVID-19 vaccination?What type of vaccine did you receive?PfizerModernaJohnson & JohnsonOtherUnsureAbout Eye & Vision InsurancePLEASE 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 open network provider with most vision plans. That means that we are not "in network providers" but we will file your insurance to reduce your costs. We research your coverage for vision services and let you know how much you will save and how much your vision plan will pay. We take care of the insurance filing for you so you don't have the headache of dealing with vision plans. PLEASE BRING YOUR INSURANCE CARD(s) WITH YOU TO YOUR APPOINTMENT AND, IF YOU CAN, PLEASE UPLOAD THEM BELOW. Medical Insurance InformationMedical Insurance*Please indicate which, if any, major medical (health) insurances you have. Blue Cross / Blue ShieldUnited HealthcareAetnaCignaHumanaMedicareI have no major medical coverageOtherPrimary Policy Holder (Medical Insurance)Last 4 Digits of Primary Policy Holder's Social Security NumberGroup ID Number (Medical Insurance)Member ID Number (Medical Insurance)Vision Plan (Insurance) InformationVision Plan*Please indicate which, if any, vision plan you have. I have no vision planAetna VisionBlue ViewCigna VisionDavis VisionEyeMedSpecteraSuperiorVSPOtherPrimary Policy Holder (Vision Plan)Last 4 Digits of Primary Policy Holder's Social Security NumberPrimary Policy Holder's Date of BirthID Number (Vision Plan)Upload Insurance CardsThis 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.Be sure to upload both vision and medical insurance cards, if you have them. Drop files here or Accepted file types: jpg, gif, png, pdf. Other CommentsPlease let us know if there are any other issues, of which we should be aware, prior to your visit.COVID-19 ProtocolsFOR EVERYONE'S SAFETY, HERE ARE SOME OF THE NEW CDC PROTOCOLS WE HAVE PUT INTO PLACE: --you will be contacted by our staff prior to your appointment if we have any questions about this registration form. --we will still have our wonderful smiles, but they will be behind face masks...we ask that you wear a face mask as well. --upon entering, we will be taking your temperature; hand disinfectant is available --please limit only essential family members in the office. IMPORTANT: If you are not feeling well, infected with COVID-19, or think you may have been infected, please contact us in advance before coming in. Let us know if we can accommodate you or your family in any way and please know that we have your best interest at heart. We are here for you, as always. Thank you for your understanding and we can't wait to see you face to face again (even under a mask!).Cancellation FeePlease kindly provide 24h notice if you must cancel for any reason. Non cancelled appointments will incur a $35 fee.EmailThis field is for validation purposes and should be left unchanged.
Closed Fridays Only from 12pm - 2:00pm