MEC Entry FormOnline Entry FormSave time and fill out information BEFORE you come into the office!"*" indicates required fields Step 1 of 812%Appointment Date MM slash DD slash YYYY Appointment Time Hours: Minutes AMPM AM/PMName* 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 PhoneInsurance 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 YesIf 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 SurgeryAre you pregnant or currently nursing? Yes NoDo you wear glasses? Yes NoDo you wear contact lenses? Yes NoIf yes, are they: Soft disposable Rigid gas permeable Hybrid OtherHave you had vision surgery? Yes NoIf yes, which? LASIK PRK RK Lens implants OTHERSocial HistoryDo you use tobacco products? Yes NoIf yes, type / amount / how long?Do you drink alcohol? Yes NoIf yes, type / amount / how long?Do you use illegal drugs? Yes NoIf yes, type / amount / how long?Have you ever been exposed to or infected with: HIV Hepatitis Syphilis Gonorrhea None of theseFamily HistoryBlindness Yes No I don't knowCataract Yes No I don't knowCrossed Eyes Yes No I don't knowGlaucoma Yes No I don't knowMacular Degeneration Yes No I don't knowRetinal Detachment Yes No I don't knowCancer Yes No I don't knowDiabetes Yes No I don't knowThyroid Disease Yes No I don't knowHigh Blood Pressure Yes No I don't knowOther Unlisted Disease / ConditionReview 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.NameThis field is for validation purposes and should be left unchanged. 78527
