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(303) 427-2020

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Services
Eye Conditions
Patient Center
About Us
Resources
- Frames
Contact
- Appointment Request

Book Appointment (303) 427-2020

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New Patient Forms

New Patient Forms

Welcome to Family Vision Center! Please take a few moments to fill out the information below so that we are prepared for your upcoming visit! Your email will not be shared with any 3rd parties and is used for occasional office announcements.

PATIENT INFORMATION

First Name*

Middle

Last Name*

Date of Birth *

Gender

Female Male Other

Email Address

Mobile Phone Number

We use mobile messaging as the fastest method for appointment reminders, order status, and live two-way communications. We will never message you promotional info. *

Alternate Phone Number

Street Address

City

State

ZIP Code

Employer

Occupation

How were you referred to our office?

MEDICAL HISTORY

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol?

Do you smoke?

Please list all major injuries and surgeries you have had and what year they occurred.

This includes eye surgeries such as LASIK and cataract surgery.

Do you have any of the following conditions? Please check all that apply.

NONE Any Cancer Cardiac Disease High Blood Pressure Diabetes Rheumatoid arthritis Multiple Sclerosis Glaucoma (or suspect) Color blindness Cataracts Macular Degeneration Amblyopia (lazy eye) Retinal Detachments Strabismus (cross eye)

Does your FAMILY have history of any of these conditions?

NONE Any Cancer Cardiac Disease High Blood Pressure Diabetes Rheumatoid arthritis Multiple Sclerosis Color blindness Glaucoma (or suspect) Cataracts Macular Degeneration Amblyopia (lazy eye) Retinal Detachments Strabismus (cross eye)

Please list any other major medical conditions that you may have:

Some examples are chronic fatigue, "blackouts" or neurological issues, irregular heart beat, shortness of breath, Crohn's disease, Shingles, frequent infections, depression, etc.

To address or treat any of the conditions you checked above at your visit the Doctors must perform a Medical Eye Exam. This exam will address your non-routine medical conditions and evaluate their impact on your vision. You will have the option to get a new prescription for glasses and/or contacts as well. Medical Eye Exams are billed to medical insurance, not vision insurance.

MEDICATION

Do you take any prescription medications?

Yes No

Please list all prescription medications you take and dosage:

OR, upload a photo or scan of your medications

Do you take regular over-the-counter medications?

Yes No

Do you have any drug allergies?

Yes No

VISION

When, approximately, was your last eye exam?

Please check any Vision sensations that apply:

Blurred Vision at Distance Blurred Vision at Near Double Vision Light Sensitivity Tired Eyes Watery Eyes Floaters or Spots Fluctuating Vision Loss of Vision Loss of Side Vision None

Please list any other eye conditions or vision problems you would like to discuss.

OPTOMAP

Optomap is a digital scan of the interior of your eye which allows the doctor to assess your eye health. It is the recommended method by the doctors, and replaces traditional chemical dilation which opens the eye so the doctor can inspect visually. Dilation does impair vision for 6-8 hours. If dilation is preferred please ensure you bring sunglasses, and make arrangements to not drive or perform vision intensive tasks for 6-8 hours immediately following your exam.

Yes, I would like Optomap for $49 No, I prefer dilation

EYEGLASSES

Do you own glasses?

Yes No

CONTACT LENSES

Contact lens examinations are elective and additional to your vision exam. Fees vary from $60-$250. Insurance does not cover this expense, and fees are due the date of the exam.

Do you wear contact lenses?

Yes No

If you do not wear contact lenses, would you like to be examined for them at your visit?

No Yes, and I have not worn contacts before Yes, and I HAVE worn contacts before but discontinued them

INSURANCE

If you would like us to bill any insurance we will need all accurate data regarding Primary and Vision Insurance.

Would you like us to bill any insurance? Check all that apply

Yes, medical insurance Yes, vision insurance Pay privately

Medical Insurance

In lieu of filling in the information below you may upload front and back images of your medical insurance card.

Medical/Primary Insurance

Member ID Number

Who is the Primary Insured Member?

First

Last

Insured Member's Social Security Number

Vision Insurance

Card Upload

Vision Plan

VSP Eyemed Spectera Other

If Other

Who is primary on the vision plan?

Self Other

Vision Insurance ID Number

Your primary medical insurance company can verify your Vision Insurance ID Number.

Insured Member's Social Security Number

Acknowledgment of Practice Policy

I agree to the Practice Policy.

See Family Vision Center Practice Policy here.

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Family Vision Center

Address

10071 Wadsworth Pkwy Suite 200,
Westminster, CO 80021

Phone

(303) 427-2020

View Directions

Monday

Closed

Tuesday

8:30 am - 12:00 pm

1:30 pm - 5:30 pm

Wednesday

8:30 am - 12:00 pm

1:30 pm - 5:30 pm

Thursday

8:30 am - 12:00 pm

1:30 pm - 5:30 pm

Friday

8:30 am - 12:00 pm

1:30 pm - 5:30 pm

Saturday

8:00 am - 1:00 pm

Sunday

Closed

Family Vision Center

(303) 427-2020

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