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SVS Vision – Patient Exam Formadmin2021-08-14T21:31:28+00:00

SVS Vision - Patient Exam Form

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Please be aware that the form below is for patients who have an upcoming appointment scheduled. If you do not have an appointment scheduled at this time and you would like to schedule one, please visit svsvision.com/contact or give your local office a call directly.
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Patient Name:*
Date of Birth:*
Patient Address:*
Marital Status*
Gender*
If none, please type "none"
Are you here for glasses, contact lenses, or medical eye problems?*
Please check all that apply
What other, if any, ocular (eye) concerns do you have today?*
Please list all concerns that you want to have addressed. If none, please type “none”
What medications are you taking currently?*
Please list all medications and supplements that you are taking. If you are taking no medications, please type "none". If you would prefer, you can bring a list of yor medications to your exam, please type "Will bring list". (Our associate can make a copy of your list of medication for record)
Do you have allergies to medication(s) or to the environment?*
If yes, please list
Do you use tobacco/smokeless tobacco products?*
Are you pregnant?

Please answer if you or your family members (grandparents, parents, or siblings) have any of the following medical conditions.

Hay Fever*
Thyroid*
Heart Disease*
Rashes*
Depression*
Arthritis*
Asthma*
Anemia*
Seizure*
Diabetes*
Kidney Disease*
High Blood Pressure*
High Cholesterol*
Cataracts*
Glaucoma*
Lazy Eye*
Macular Degeneration*
Retinal Detachment*
Eye Surgery/Injury*
Weight Loss*
Unexplained Headaches*
Light Sensitivity*
Itching*
Dryness*
Flashes of light*
Floaters*
Issues with car headlights*
Fluorescent light sensitivity*
Other (please list)*
Others, please list:

Please sign below to acknowledge that the information given on this form is current:

Consent*
Check to confirm that the details of this form are accurate and up to date
Type your Full Name*
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Insurance Information

Is there a vision insurance you would like to use at the time of your appointment?*
Policy Holder Name:*
Policy Holder's Date of Birth:*
Do you have a secondary vision insurance?*
Policy Holder Name:*
Policy Holder's Date of Birth:*
I hereby authorize payment of my insurance benefits to SVS Vision, Inc. for expenses incurred on this date for the above-named patient. I further authorize SVS Vision, Inc. to submit claims and supporting information for goods and procedures indicated below and for equivalent goods and procedures according to my insurance carrier’s guidelines. I understand that SVS Vision, Inc. will verify my insurance and obtain any authorizations necessary. I acknowledge that this is not a guarantee of payment by my insurance carrier, and, unless otherwise prohibited, I am responsible for any and all charges not covered by my insurance plan.
Type your Full Name*
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Click Here to Download our Privacy Policy

Receipt of Privacy Policy Notice*
I, (Please enter full legal name above), the “Patient” or “Patient’s legal representative” (if the patient is a minor or an adult who is unable to sign this form) have been presented with the Notice of Privacy Policy (the “Policy” of SVS Vision), and have been offered a copy of such policy to keep for my records.
I am the:*
Type your Full Name*
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Type your Full Name*
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Name of Patient’s Representative:
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