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Target Optical
admin
2017-07-06T01:14:32+00:00
Target Optical
Preferred Provider
(select)
John Riley
Kerri Luce
Patient Information
Name
First
Last
Cell Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Occupation
Account Responsible Information
Information about person responsible for bill. Only need address if different than patients.
Relationship to Patient
(select)
Child
Legal Guardian
Domestic Partner
Handicapped Child
Other
Self
Spouse
Student
Salutation
(select)
Dr.
Fr.
Miss
Mr.
Mrs.
Ms.
Rev.
Sr.
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Insurance Information
Type Insurance Company under Company Name. Eyemed patients have no ID #, VSP ID last 4 of primary SS #.
Company Name
Insured person employer/school
Insured person relationship
(select)
Child
Legal Guardian
Domestic Partner
Handicapped Child
Other
Self
Spouse
Student
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Insured person gender
(select)
Female
Male
Insurance number
Medications
If no medication used, go on to next section, BUT PLEASE LIST ANY YOU ARE TAKING.
Name
Date Started
Allergeries
If NO Alergeries, go on to next section.
Name
Reaction
Severity
General History
Primary Care Phyisican
Last Visit
Do you work on a computer?
Yes
No
Hours per day?
Ocular History
Last eye exam
Patient's Health History
Check all that apply, or "Negative" if the patient has none of the conditions listed
Eye
Negative (I have no known medical eye problems)
Amblyopia (lazy eye)
Cataract
Glaucoma
Eye Surgery - Cataract
Eye Surgery - Cornea
Eye Surgery - Refractive (Lasik, RK, etc.)
Eye Surgery - Retinal
Eye Surgery - Retinal
Eye Surgery - Strabismus (eye turn)
Macular Degeneration
Retinal Disease
Strabismus (eye turn)
Other
General/Constitutional
Negative (I have no general health issues)
Fibromyalgia
Cancer
Other
Ears/Nose/Mouth/Throat
Negative (I have no known ear/nose/throat problems)
Hay fever
Dry mouth
Sore throat
Earache
Other
Cardiovascular
Negative (I have no known heart or vascular problems)
High Blood Pressure
Heart Disease
High cholesterol
Arrhythmia
Murmur
Pacemaker
Other
Respiratory
Negative (I have no known breathing problems)
Asthma
Bronchitis
Emphysema
COPD
Lung cancer
Tuberculosis
Other
Gastrointestinal
Negative (I have no GI problems)
Gall bladder disease
Acid Reflux
Jaundice
Other
Genitourinary
Negative (I have no urinary/kidney problems)
Dialysis
Kidney disease
Other
Musculoskeletal
Negative (I have no known musculoskeletal problems)
Rheumatoid Arthritis
Osteoporosis
Muscle Pain
Joint Pain
Back Pain
Swelling of joints
Other
Integumentary
Negative (I have no skin problems)
Skin Rashes
Dry Skin
Psoriasis
Other
Neurological
Negative (I have no skin problems)
Dizziness/vertigo
Epilepsy
Seizures
Migraines
Numbness
Paralysis
Multiple Sclerosis (MS)
Other
Psychiatric
Negative (I have no known psychiatric problems)
Anxiety
Depression
Other
Endocrine
Negative (I have no known endocrine problems)
Diabetes (Type I)
Diabetes (Type II)
Hyperthroid
Hypothroid
Addison's Disease
Cushing's Syndrome
Grave's Disease
Hashimoto's
Pituitary Disorder
Other
Lymphatic/Hematological
Negative (I have no known blood/lymphatic problems)
Anemia
Bleeding Problems
Ease of bruising
Leukemia
Other
Allergic/Immunologic
Negative (I have no known allergies or immune problems)
Seasonal Allergies
Chronic Allergies
Arthritis
Lupus
HIV/AIDS
Other
Family Health History
(cancer, diabetes, heart, hypertension, thyroid, glaucoma, cataracts, macular degeneration, etc.)
Disease
Relationship
Details
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