Forms

Please complete ONE Vision and Eye Health History*


Online Form

Vision and Eye Health History

  • For New Patients, follow the directions for a New Patient.
  • For Returning Patients, we will provide you with a pass-code to update your existing information.

Printable Form

Vision and Eye Health History


Important information for your upcoming appointment:

In order to keep your appointment timely, please complete and return all necessary forms prior to your appointment date.  You may also fax your completed forms to 541-342-6153 or mail them.  Please do not mail forms if your appointment is within three days.  Please arrive at least 10 minutes  prior to your appointment to allow us to review your completed information.

Please note that if your pupils are dilated during the examination, the pharmaceutical used for this procedure can require up to 30-40 minutes to take effect. Please allow at least 1 ½ hours for this appointment.  If you wear glasses, please bring all current prescription glasses with you to your appointment.  If you have contact lenses, please wear your contact lenses to your appointment and bring your contact lens packages with you to confirm your contact lens parameters.

It is important to keep your scheduled appointment.  Please call at least 48 hours ahead of time if you need to reschedule or cancel your appointment.  Failure to provide adequate notice may result in an administrative fee.  We understand and are sympathetic to emergencies in life and will make a concerted effort to reschedule patients who are unable to keep their scheduled appointments.

As a courtesy, if you are insured, we will bill your insurance company.  Patients are responsible for payment of any non-covered charges, co-pays or deductibles at the time of service.  Please bring both your medical and your vision insurance cards with you.  A copy of your insurance card with group numbers and the billing address of your insurance company is required to bill your insurance.


What Forms Do I Download?

The information from the Online Vision and Eye Health History should be completed only once-you can not re-enter to change or update it. It will be imported directly into your medical record so it is available on the day of your visit, saving you valuable time in the office. This also gives you an opportunity to tell us about you or your child in great depth. This information is very helpful for us to review ahead of time and we appreciate you filling it out well in advance of your appointment.

Included in this Medical History are the following Sections.

  • VISION AND EYE HEALTH HISTORY
  • PEDIATRIC HISTORY (for children 12 years of age and younger)
  • SCHOOL RELATED HISTORY (for students)
  • READING AND COMPUTER SYMPTOM CHECKLIST (for children and adults)
  • DRY EYE HISTORY
  • BRAIN INJURY HISTORY (stroke, head injury, concussion, whiplash, motor vehicle accident, bike accident, etc.)
  • VISION MOTION SENSITIVITY CHECKLIST (Dizziness, motion sickness, car sickness, etc.)
  • SPORTS VISION HISTORY (Professional athletes and weekend warriors)

Please complete all sections which are appropriate for you or your child. You are welcome to skip any question if you do not know the answer.  If you wish to have a teacher contribute comments and observations regarding your child’s observable traits in the classroom, please print the Educator’s Checklist of Observable Clues to Classroom Vision Problems, and request that the teacher complete the form and return it to you to bring to your child’s appointment.

This electronic method of submitting vision and eye health information is completely encrypted and secure utilizing our Practice Management Software’s Server. If, however, you are uncomfortable sending your information over the internet, please print the Printable Vision and Eye Health History and Fax it to us at 541-342-6153 or drop it off at our office prior to your appointment day. If you are unable to provide the history form ahead of time, please bring it with you to the office 15 minutes prior to your appointment time.

If you need records sent to us, please print the Records Release and fill it out. When you fax or deliver this release form to your previous or referring doctor, they will forward the records you request to our office. Please allow 3-5 business days for the records to be forwarded.

By law, we are not permitted to release any information about you to anyone, other than your referring and/or consulting physician(s) and your health insurance company, without your written consent.  If there are family members, i.e. spouse, children, or friend you would like to designate to receive information or be able to inquire regarding your medical status and treatment, please print and complete the Authorization to Release Information.  By listing these names and relationships you are providing our office with permission to discuss your medical status when they contact us on your behalf.

To review our privacy practices, please click on the Privacy Practices. You will be asked to sign a consent form when you arrive for your appointment indicating that you have had an opportunity to review this form.

Thank you for helping us prepare for your examination. We look forward to seeing you shortly at Lifetime Eye Care.