Adult Patient Form

2260 Oakmont Way, Suite 1 | Eugene, OR 97401
P 541.342.4243 | F 541.284.2958 | foleyvisioncenter.com
 
General Information - Photo ID REQUIRED AT VISIT
* Full Legal Name (as it appears on driver's license or other government ID)

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Phone

Home  Work  Cell

Home  Work  Cell

Home  Work  Cell
* OK to text Preferred Phone Number?
 
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Emergency Contact Section
 
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Per the Health Care Act we are required to record your height and weight at each visit.

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ft.in.
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lbs.
 
Insurance Information
 
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Patients with Insurance: At the time of treatment, patients are expected to pay their estimated charges. An estimate of cost will be provided to you at the time of your appointment. Insurance portion is only an estimate and any balance remaining after insurance payment is patient's responsibility.
 

Patients without Insurance: Patients without insurance are required to pay the charges in full at the time service is provided. A total cost will be provided to you at the end of your appointment.


Please fill out any vision insurance below. Policy numbers may change even if your coverage has remained the same, so please fill out every year. If information is missing or incorrect, your visit may not be billed correctly to your insurance.
Please answer “N/A” if you do not have coverage.
 
Name of Primary Member Insured (as it appears on insurance card)
Birth Date of Primary Member Insured
SSN (last 4 digits) of Primary Member Insured
        
 



Please fill out any medical insurance below. Policy numbers may change even if your coverage has remained the same, so please fill out every year. If information is missing or incorrect, your visit may not be billed correctly to your insurance.
Please answer “N/A” if you do not have coverage.
 
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* Birth Date of Primary Member Insured
* SSN (last 4 digits) of Primary Member Insured
        



 
Primary Care Practitioner:
​​​ Additional Providers:
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CHIEF COMPLAINTS TODAY (or over the last week)
GLASSES
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Do you plan on purchasing new glasses today?
CONTACTS
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hours
* Just a reminder a $55-75 contact lens evaluation fee is charged for annual contact lens exams.
OCULAR SURFACE DISEASE SURVEY
Do your eyes ever feel or do you experience: Never Slight Moderate Severe
* Gritty or Sandy Sensation?
* Pain or Soreness?
* Fluctuating Vision?
* Occasional Tearing?
* Discomfort in Windy Conditions and/or Heating/Air Conditioned Areas?
ALLERGY SURVEY
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SURGICAL HISTORY
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MEDICAL HISTORY
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COVID VACCINES * Have you had a COVID-19 vaccine?




 



List any medications you take, Rx or OTC/Supplements and Condition

If you don’t know what condition per medication, please put “Unknown”
 
OCULAR:
Amblyopia (Lazy Eye)
   
Blindness
   
Cataract(s)
   
Color Deficiency
   
Glaucoma
   
Keratoconus
   
Macular Degeneration
   
Ptosis (Drooping Lid)
   
Retinal Detachment
   
Retinal Tear
   
Strabismus (Eye Turn)
   
Other: 
   
 
MEDICAL:
Androgen Deficiency
   
Arthritis
   
Acne Rosacea
   
Cancer
   
Cholesterol
   
Crohns
   
Diabetes Type 1
   
Diabetes Type 2
   
Ehlo's Danlos Syndrome
   
Facial Herpes Zoster (Shingles)
   
Heart Disease
   
Hepatitis C
   
High Blood Pressure
   
Kidney Disease
   
Lupus
   
Migraines
   
Sarcoidosis
   
Sjogren's Syndrome
   
Sleep Disorders
   
Stroke
   
Thyroid Disease
   
Other: 
   
 
SOCIAL HISTORY
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Our goal is to provide the best, most complete, up-to-date care available. Our philosophy is preventive and developmental in approach. To provide this service in the most efficient manner, please be aware of the following office policies:

  • Fees for services are due at the time those services are rendered.
  • Payment in full at time of ordering.
  • We reserve the right to charge for missed appointments not canceled in advance.
  • Vision Therapy patients must notify us of absences in advance.
  • There is a charge for written reports.
  • Responsibility for payment is the patient’s. Insurance agreements are between the company and the patient. We will assist with proper forms but require reimbursement from patients.
 

By signing this form electronically, and clicking on “Submit Form,” you are agreeing to the terms and conditions stated herein. The signee understands this is a legal representation of their written signature.


* Print Your Legal Name
 

Signature
If using a touch screen device, use your finger to sign. If using a computer, hold down the left button and use the mouse as a pen.

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