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Please note: All Missouri Eye Consultants locations will be closed Monday, May 25th for Memorial Day
and Friday, July 3rd for the Independence Day holiday weekend.

MEC Entry Form

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Insurance Info

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We 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 History

List the medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):

Do you have any allergies to medications?*

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Yes

If yes, explain:

List all major surgeries, injuries and/or hospitalizations you have had:

Check 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 History

Do 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 History

Blindness

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 Symptoms

Fever, Weight Loss / Gain

Skin

Headaches

Migraines

Seizures

Loss of Vision

Blurred Vision

Loss of Peripheral Vision

Double Vision

Mucous Discharge

Red Eyes

Itching

Glare / Halos / Light Sensitivity

Chronic Eye Infections

Flashes / Floaters

Computer Eye Strain

Dry Eyes

Thyroid / Other Glands

Allergies / Hay Fever

Sinus Congestion

Dry Mouth / Throat

Asthma

Emphysema

Diabetes

High Blood Pressure

Vascular Disease

Constipation

Genitals / Kidney / Bladder

Rheumatoid Arthritis

Muscle / Joints Pain

Anemia / Bleeding Problems

Allergic / Immunologic

Psychiatric

If you have answered yes to any of these, please explain below.

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Ashland: +1 (573) 770-3136
California: +1 (573) 877-7321
Columbia (Keene): +1 (573) 993-3407
Columbia (Nifong): +1 (573) 969-3030
Macon: +1 (573) 993-3603
Moberly: +1 (573) 877-7318
Fulton: +1 (573) 828-2265

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Ashland: +1 (573) 770-3136
Columbia (Keene): +1 (573) 993-3407
Columbia (Nifong): +1 (573) 969-3030

×

Columbia (Keene): +1 (573) 993-3407
Columbia (Nifong): +1 (573) 969-3030

×

Ashland: +1 (573) 770-3136
California: +1 (573) 877-7321

×

Ashland: +1 (573) 770-3136
Columbia (Keene): +1 (573) 993-3407
Columbia (Nifong): +1 (573) 969-3030

×

Macon: +1 (573) 993-3603
Moberly: +1 (573) 877-7318

×

Columbia (Keene): +1 (573) 993-3407
Fulton: +1 (573) 828-2265

×

Columbia (Keene): +1 (573) 993-3407
Columbia (Nifong): +1 (573) 969-3030

×

Columbia (Nifong): +1 (573) 969-3030
Macon: +1 (573) 993-3603

×

Columbia (Keene): +1 (573) 993-3407
Macon: +1 (573) 993-3603

×