Eyes on Main Welcome Consent FormPlease enable JavaScript in your browser to complete this form.First Name *Middle NameLast Name *SuffixBy reading and acknowledging this form, I understand that risks can occur with electronic submission of confidential health information. I am aware that communications via e-mail and over the internet, although safeguarded, are not 100% secure. We only collect and have access to personal and health information that you voluntarily give us. We will not sell or share your information to any third party without your consent. The information you provide is treated as confidential and is used solely for your care and to file any insurance claims or reports related to the management of your care. If you have any concerns about the electronic submission of your personal health information, please do not continue with completion of this form, and instead call our office with questions for additional options. *AcceptDeclineOur staff will contact you on next steps for completion.How do you prefer to be addressed (nick name)?Date of Birth *Gender *MaleFemaleOtherPreferred Language *EnglishAfrikaansAlbanianArabicArmenianBasqueBengaliBulgarianCatalanCambodianChinese (Mandarin)CroatianCzechDanishDutchEstonianFijiFinnishFrenchGeorgianGermanGreekGujaratiHebrewHindiHungarianIcelandicIndonesianIrishItalianJapaneseJavaneseKoreanLatinLatvianLithuanianMacedonianMalayMalayalamMalteseMaoriMarathiMongolianNepaliNorwegianPersianPolishPortuguesePunjabiQuechuaRomanianRussianSamoanSerbianSlovakSlovenianSpanishSwahiliSwedishTamilTatarTeluguThaiTibetanTongaTurkishUkrainianUrduUzbekVietnameseWelshXhosaRace *American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhitePhone *Is this a cell phone?YesNoCan we text you?YesNoSecond PhoneEmail *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocSec#*Needed to process most insurance claimsEthnicity *Hispanic/LatinoNon-Hispanic/LatinoPrimary Care PhysicianPreferred Pharmacy Name & LocationMedical & Health Insurance *Choose from the followingAetnaASRBlue Cross/Blue Shield (BCBS)Blue Cross Complete MedicaidBlue Care Network (BCN)CignaCofinityGolden RuleHumanaHumana MilitaryMcLaren MedicaidMolina MedicaidMedicareMeridian MedicaidMeridian/Wellcare Health PlanMICHILDPriority HealthPriority Health MedicaidSet/SegStraight MedicaidTricareUnited HealthcareUnited Healthare Community PlanOtherNone/Self PayIf you are unsure of your insurance, please call the office. If we do not have the information needed, there is a chance we will be unable to bill your insurance.Policy # *Policy Holder Name: *Policy Holder Date of Birth *Policy Holder's Last 4 Soc. Sec. # *Vision Insurance *Choose from the followingMedicaidAARP (Vision Discount)ASRDavis Vision (Arconic Manufacturing only)Delta VisionEyemedHeritage VisionVision Service Plan (VSP)OtherNone/Self PayIf you are unsure of your insurance, please call the office. If we do not have the information needed, there is a chance we will be unable to bill your insurance.Policy #Policy Holder NamePolicy Holder Date of BirthPolicy Holder's Last 4 Soc. Sec. #Other InsurancePolicy #Policy Holder Date of BirthPolicy Holder NamePolicy Holder's Last 4 Soc. Sec. # How did you hear about us?Google AdsInsuranceSchoolDrive by buildingSocial MediaFriend/RelativeIf a personal referral, who may we thank for referring you?(Name)Do you smoke? *YesNoAre you pregnant? *YesNoDo you drink alcohol? *YesNoAre you nursing? *YesNoHealth HistoryHealth History: Diabetes *SelfRelativeNoneHealth History: High Blood Pressure *SelfRelativeNoneHealth History: Thyroid Problems *SelfRelativeNoneHealth History: Heart Disease *SelfRelativeNoneHealth History: Asthma *SelfRelativeNoneHealth History: Cancer *SelfRelativeNoneHealth History: Seizures *SelfRelativeNoneHealth History: Stroke *SelfRelativeNoneHealth History: Glaucoma *SelfRelativeNoneHealth History: Cataracts *SelfRelativeNoneHealth History: Macular Degeneration *SelfRelativeNoneHealth History: Retinal Disease *SelfRelativeNoneHealth History: Eye Surgery *SelfRelativeNoneHealth History: Eye Injury *SelfRelativeNoneHealth History: OtherPlease explainReason for your visit todayReason for your visit today *Blurred VisionBurningDry EyeEye PainEye StrainFlashing LightsFloatersHeadachesItchingNight GlareRednessSensitive to LightWateringOtherAllergies & MedicationsList Any Allergies*including allergies to medicationsMedications *(no need to write if list provided)Please Read and SignI acceptI authorize Lakeshore Professional Eyecare / Eyes on Main / West Ottawa Eyecare to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to Lakeshore Professional Eyecare / Eyes on Main / West Ottawa Eyecare. Vision plans only cover routine vision wellness exams, along with eyeglasses and contact lenses. Vision plans do not cover medical eye care (the diagnosis, management or treatment of eye health problems). Medical insurance must be used for medical eye care. I understand that if I have both types of insurance plans it may be necessary to bill some services to one plan and some services to the other, using a procedure called coordination of benefits to do this properly and to minimize out-of-pocket expense. I understand that if fees are not paid by my insurance, I am still responsible and will be billed for them. Accounts 90 days old are subject to collections, and there will be a service charge for any bounced checks. I understand that if I do not show up for an appointment on two occasions or reschedule an appointment on short notice twice in one year, I may be discharged as a patient at LPE’s discretion. HIPAA Notice of Privacy Policies: I understand I may obtain a copy of Lakeshore Professional Eyecare’s Notice of Privacy Practices upon request. *I accept Health related communications and reminders: I permit Lakeshore Professional Eyecare to communicate and remind me about my health related issues and appointments by phone, texting and/or email. *I acceptToday's Date *Type name for electronic signature *Parent/guardians need to sign for minorsCheck this box if you filling out the form on a patient's behalf.Additional CommentsPlease solve the equation in the Captcha box *What is 7+4? Submit