RETURN PATIENT REGISTRATION FORM

**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 First Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Please provide a cell phone number, with area code, so we can contact you.

Email Address

Please provide us your email address.

Please Update Any Information, if changed

Marital Status

Marital Status - Other

Please provide your marital status, if not listed above.

Employment Status

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

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)

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?*

YES
NO

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?*

Check all that apply:

Good - No Change
Blurry at Distance
Blurry at Near
Blurry at Computer Distance

Do you have an extra / spare / older pair of glasses which can be used in an emergency?*

NO
YES

Would 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)?*

NO
YES

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.

Contact Lens Information & Updates

Do you currently have or wear contact lenses?*

YES
NO

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?

How comfortable are your contact lenses?

How often do you replace or dispose of your contact lenses?

With what brand of solution do you clean & store your lenses?

What is your typical contact lens wearing schedule?

Please 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 & Updates

Who is your primary care physician?

Do you smoke?*

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.

YES
NO

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

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.

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

Max. file size: 2 MB.

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 Glasses, Contact Lenses, and Routine Eye Exams. We are OUT OF network provider for all vision plans. You may be able to file for any vision benefits after the fact, but our office does not do any filings.

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.

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)

Upload Insurance Cards

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 plans at our office, only medical.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

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*

I have read and agree to the Privacy Policy

Consent*

I acknowledge receipt of the Notice of Privacy Practices (form 9/23/13) from Dr. Robert Janot-Vision Source. Please sign below to confirm acknowledgment:*

Signature*

E-MAIL &/OR TEXTING*

Check here to authorize us to communicate with you via e-mail &/or text messaging regarding appointments, changes, status of your eyewear orders, etc. Your information is NOT shared with others. We may also use e-mail or texting for issues regarding your eye health and/or other personal health information. Sign here if you consent:

Signature*

Release of Eyeglass / Contact Lens Prescriptions*

I give consent to Dr. Robert Janot – Vision Source to provide my prescriptions to me via my electronic patient portal where I may access / print my prescriptions once my exam is finalized. Sign here if you consent:

Signature*

Cancellation Fee

Please kindly provide 24h notice if you must cancel for any reason. Non cancelled appointments will incur a $35 fee.

Comments

This field is for validation purposes and should be left unchanged.