**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.
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
Please provide us your email address.
Please Update Any Information, if changed Marital Status Select Marital Status > Child Divorced Legally Separated Married Single Widowed Other Marital Status - Other
Please provide your marital status, if not listed 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
Please provide your employment status.
Employer Occupation 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 Last 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 & Updates Do you currently have or wear eyeglasses? * Current Glasses Being Worn
If 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? * Would you like more information on any of the following? (Please indicate all that apply) Do you plan to change / update / purchase new glasses at this visit? * Any pain or irritation in or around your eye(s)? * If 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.
1 2 3 4 5 6 7 8 9 10 Contact Lens Information & Updates Do you currently have or wear contact lenses? * Current Contacts Being Worn
If 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 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 No solution, I change my lenses daily Unique pH (gas permeable, scleral lenses) Boston Simplus (gas permeable lenses) Boston Original (gas permeable lenses) Boston Advance (gas permeable lenses) 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 Information & Updates 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 IF 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. Please list any NEW medical conditions which have been developed since your last visit here Please list any NEW prescription and over-the-counter medications since your last visit here List any medication(s) that you have DISCONTINUED since your last visit here Upload Medication List
If you have a current list of your medications and are able to upload it, you may do so here.
Drop files here or Select files Max. file size: 31 MB. 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: 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 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.
Be sure to upload both vision and medical insurance cards, if you have them.
Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 31 MB. Other Comments
Please let us know if there are any other issues, of which we should be aware, prior to your visit.
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.
Closed Fridays Only from 12pm - 2:00pm