MEC Entry Form Online Entry FormSave time and fill out information BEFORE you come into the office! "*" indicates required fields Step 1 of 8 12% Appointment Date MM slash DD slash YYYY Appointment Time Hours : Minutes AM PM AM/PM Name* First Last Today's Date MM slash DD slash YYYY Personal InformationAddress Street Address City State / Province / Region ZIP / Postal Code Birth Date MM slash DD slash YYYY Email Phone*EmployerOccupationGuardian (if applicable) First Last How did you hear about our practice?Give them credit! Please enter the name of the service or person who referred you to us. Last Eye Exam MM slash DD slash YYYY Medical DoctorEmergency Contact First Last Emergency Contact Phone Insurance InfoInsurance CarrierWe are providers for Medicare, Missouri Medicaid, Essence, Cigna, Blue Cross/Blue Shield, Vision Care Direct, UMR, United Healthcare, Coventry, Humana, VSP, EyeMed, Delta Vision, Advantica and Healthlink. If you have other insurance, we will provide you with an itemized receipt on the day of your examination that you may file with your insurance company. If you do not have one of the plans we accept, payment is requested on the day services are rendered. Medical HistoryList the medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):Do you have any allergies to medications?* No Yes If yes, explain:List all major surgeries, injuries and/or hospitalizations you have had: Add RemoveCheck any of the following that you have had: Crossed Eyes Lazy Eye Glaucoma Retinal Disease Cataracts Eye Infections Eye Injury Eye Surgery Are you pregnant or currently nursing? Yes No Do you wear glasses? Yes No Do you wear contact lenses? Yes No If yes, are they: Soft disposable Rigid gas permeable Hybrid Other Have you had vision surgery? Yes No If yes, which? LASIK PRK RK Lens implants OTHER Social HistoryDo you use tobacco products? Yes No If yes, type / amount / how long?Do you drink alcohol? Yes No If yes, type / amount / how long?Do you use illegal drugs? Yes No If yes, type / amount / how long?Have you ever been exposed to or infected with: HIV Hepatitis Syphilis Gonorrhea None of these Family HistoryBlindness Yes No I don't know Cataract Yes No I don't know Crossed Eyes Yes No I don't know Glaucoma Yes No I don't know Macular Degeneration Yes No I don't know Retinal Detachment Yes No I don't know Cancer Yes No I don't know Diabetes Yes No I don't know Thyroid Disease Yes No I don't know High Blood Pressure Yes No I don't know Other Unlisted Disease / Condition Review of SymptomsFever, Weight Loss / GainSkinHeadachesMigrainesSeizuresLoss of VisionBlurred VisionLoss of Peripheral VisionDouble VisionMucous DischargeRed EyesItchingGlare / Halos / Light SensitivityChronic Eye InfectionsFlashes / FloatersComputer Eye StrainDry EyesThyroid / Other GlandsAllergies / Hay FeverSinus CongestionDry Mouth / ThroatAsthmaEmphysemaDiabetesHigh Blood PressureVascular DiseaseConstipationGenitals / Kidney / BladderRheumatoid ArthritisMuscle / Joints PainAnemia / Bleeding ProblemsAllergic / ImmunologicPsychiatricIf you have answered yes to any of these, please explain below.PhoneThis field is for validation purposes and should be left unchanged. 86621
