Welcome to Our Office

Professional Vision Services LLC serves patients of all ages in the Defiance, OH area. Please fill out the below forms in order to make sure you get the best of care.

If this is your first time in our office, fill out the below form. If you're a returning patient, click here.

Appointment Date

Date of Last Exam

Patient Information

Patient Information (According to Record)

Last

First

Home Address

City

State

Zip code

Primary Phone

Work Phone

Secondary Phone

Patient's Date of Birth

Age

Sex

Employer/School

Occupation/Grade

Patient Information (Changes Only)

Patient Information (Changes Only)

(Please complete in the corresponding field below any information that is either incomplete or incorrect in our records. Thank you.)

Last

First

Home Address

City

State

Zip code

Primary Phone

Work Phone

Secondary Phone

Patient’s Date of Birth

Age

Sex

Employer/School

Occupation / Grade

Spouse/Parent’s Name

Spouse/Parent’s Work

Spouse/Parent’s DOB

Insurance Information

Insurance Information

Vision Insurance Provider

Primary Medical Insurance

Secondary Ins.?

Yes

Subscriber’s Name

Group Number

Do you participate in a Flex spending account?

Yes

How will you settle your account today?

Cash

Check

Credit card

Current Eye Health

Current Eye Health

What is the major purpose of this visit?

Any problems with your current contact lens and/or glasses?

Contact Lens History

Contact Lens History

Have you ever tried contact lens?

Yes

Do you currently wear contacts?

Yes

If yes then, what kind?

Cleaning solution used?

Are you satisfied with the comfort of your contacts?

Yes

Do you prefer

Clear

Colored contact lenses

Very Important! New Patients Only

Very Important! New Patients Only

Whom may we thank for referring you to our office?

If not referred, how did you choose our office?

Another Doctor

Insurance List

Saw Sign/Building

Newspaper/Radio/TV

Yellow Pages: Which Directory?

Web Page: Which Site?

Other

Additional information to be completed on back.

Additional information to be completed on back.

mission

The mission of Professional Vision Services is to contribute to a lifetime of healthy vision, providing each patient with the highest quality vision care and consequent quality of life. We will seek continuing education to remain at the forefront of our profession and will offer the latest eye care technology, professional services, and products. The visual needs and wellness of each patient will always be our first priority. Everything we do shall communicate this.

Please, if you have your insurance cards we would like to make a scan for our records.

Please, if you have your insurance cards we would like to make a scan for our records.

Lifestyle Questions

Lifestyle Questions

Do you……(check box if your answer is yes)

..work/play at a computer?

..think you might benefit from thinner, lighter lenses?

..have interest in a “test drive” of the latest contact lens designs

..spend time outdoors? How much? Hrs/week

..have prescription sunwear?

..prefer not to wear your glasses at times?

..want information on Laser Vision Correction surgery?

..have interest in a non-surgical approach to vision correction?

..have more than 1 pair of current Rx eyewear?

..have children?

..wear bi-focals and are bothered by head tilting?

Medical History

Medical History

Name of Family Physician

Town

Date of Last Physical Check-up

CURRENT MEDICATIONS (Rx or Over the Counter)

CURRENT MEDICATIONS (Rx or Over the Counter)

(List name of medications including eye drops, vitamins, & birth control pills)

If you have a list of your medications, we can copy.

If you have a list of your medications, we can copy.

Allergies to medications?

Yes

If so, what medications?

Have you had any surgeries?

Yes

Do you use cigarettes/tobacco, alcohol, or other substances?

Yes

Is there a family medical history of any of the following:

Yes (Please check boxes)

Field label

Relationship

(Mother's or Father's side)

Blindness

Relationship 1

Cataracts

Relationship 2

Corneal Problems

Relationship 3

Diabetes

Relationship 3

Glaucoma

Relationship 4

Heart Disease

Relationship 5

Lazy Eye

Relationship 6

Macular Degeneration

Relationship 7

Retinal Problems

Relationship 8

Date of your last vision analysis?

Date of your last vision analysis?

Here (information on file)

Other (When)

When

By Whom?

Whom

Have you ever experienced, been diagnosed or treated for any of the following?

Have you ever experienced, been diagnosed or treated for any of the following?

Health Disorders

Blurry Vision

Cataracts

Crossed eye/Eye turn

Eye Infections

Flash of light

Glaucoma

Headaches

Itchiness

Macular Degeneration

Retinal Detachment

Tearing

Uncomfortable glasses

Burning

Double Vision

Eye Injury

Floaters/Spots

Grittiness

Iritis/Uveitis

Lazy Eye

Occasional dryness

Sunlight Sensitivity

Trouble seeing at night

Other eye disorders

Have you ever been diagnosed or treated for the following health problems?

Have you ever been diagnosed or treated for the following health problems?

Yes

Allergies

Arthritis

Blood/Lymph

Bronchitis

Cancer

Cholesterol

Diabetes

Digestive

Ears/Nose/Throat

Endocrine (hormonal glands)

Eczema/Rashes

Fatigue

Fevers

Genitourinary (reproductive or urinary)

High Blood Pressure

Integumentary (Skin)

Kidney

Muscle/Bone

Neurological

Psychological

Respiratory

Sinus

Throat Infections

Thyroid

Unusual weight losses/gains

Free Text

Please be advised if you are using insurance coverage for today's visit, this is a contract between you and your insurance company...not Professional Vision Services.

If your insurance company has not reimbursed our office in full within 60 (or 90) days, you will be billed by us, and your insurance company will then pay you directly. (If by mistake your insurance company sends the payment check to us, we will of course credit your account and if requested can reimburse you by check.)

Free Text

The information in this confidential case history form is critical to the evaluation of your vision and health.

Signature

Upload File

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Welcome Back to Our Office

Appointment Date

Date of Last Exam

Patient Information

Patient Information (According to Record)

Last

First

Home Address

City

State

Zip code

Primary Phone

Work Phone

Secondary Phone

Patient's Date of Birth

Age

Sex

Employer/School

Occupation/Grade

Patient Information (Changes Only)

Patient Information (Changes Only)

(Please complete in the corresponding field below any information that is either incomplete or incorrect in our records. Thank you.)

Last

First

Home Address

City

State

Zip code

Primary Phone

Work Phone

Secondary Phone

Patient’s Date of Birth

Age

Sex

Employer/School

Occupation / Grade

Spouse/Parent’s Name

Spouse/Parent’s Work

Spouse/Parent’s DOB

Insurance Information

Insurance Information

Vision Insurance Provider

Primary Medical Insurance

Secondary Ins.?

Yes

Subscriber’s Name

Group Number

Do you participate in a Flex spending account?

Yes

How will you settle your account today?

Cash

Check

Credit card

Current Eye Health

Current Eye Health

What is the major purpose of this visit?

Any problems with your current contact lens and/or glasses?

Contact Lens History

Contact Lens History

Have you ever tried contact lens?

Yes

Do you currently wear contacts?

Yes

If yes then, what kind?

Cleaning solution used?

Are you satisfied with the comfort of your contacts?

Yes

Do you prefer

Clear

Colored contact lenses

Very Important! New Patients Only

Very Important! New Patients Only

Whom may we thank for referring you to our office?

If not referred, how did you choose our office?

Another Doctor

Insurance List

Saw Sign/Building

Newspaper/Radio/TV

Yellow Pages: Which Directory?

Web Page: Which Site?

Other

Additional information to be completed on back.

Additional information to be completed on back.

mission

Please, if you have your insurance cards we would like to make a scan for our records.

Please, if you have your insurance cards we would like to make a scan for our records.

Lifestyle Questions

Lifestyle Questions

Do you……(check box if your answer is yes)

..work/play at a computer?

..think you might benefit from thinner, lighter lenses?

..have interest in a “test drive” of the latest contact lens designs

..spend time outdoors? How much? Hrs/week

..have prescription sunwear?

..prefer not to wear your glasses at times?

..want information on Laser Vision Correction surgery?

..have interest in a non-surgical approach to vision correction?

..have more than 1 pair of current Rx eyewear?

..have children?

..wear bi-focals and are bothered by head tilting?

Medical History

Medical History

Name of Family Physician

Town

Date of Last Physical Check-up

CURRENT MEDICATIONS (Rx or Over the Counter)

CURRENT MEDICATIONS (Rx or Over the Counter)

(List name of medications including eye drops, vitamins, & birth control pills)

If you have a list of your medications, we can copy.

If you have a list of your medications, we can copy.

Allergies to medications?

Yes

If so, what medications?

Have you had any surgeries?

Yes

Do you use cigarettes/tobacco, alcohol, or other substances?

Yes

Is there a family medical history of any of the following:

Yes (Please check boxes)

Field label

Relationship

(Mother's or Father's side)

Blindness

Relationship 1

Cataracts

Relationship 2

Corneal Problems

Relationship 3

Diabetes

Relationship 3

Glaucoma

Relationship 4

Heart Disease

Relationship 5

Lazy Eye

Relationship 6

Macular Degeneration

Relationship 7

Retinal Problems

Relationship 8

Date of your last vision analysis?

Date of your last vision analysis?

Here (information on file)

Other (When)

When

By Whom?

Whom

Have you ever experienced, been diagnosed or treated for any of the following?

Have you ever experienced, been diagnosed or treated for any of the following?

Health Disorders

Blurry Vision

Cataracts

Crossed eye/Eye turn

Eye Infections

Flash of light

Glaucoma

Headaches

Itchiness

Macular Degeneration

Retinal Detachment

Tearing

Uncomfortable glasses

Burning

Double Vision

Eye Injury

Floaters/Spots

Grittiness

Iritis/Uveitis

Lazy Eye

Occasional dryness

Sunlight Sensitivity

Trouble seeing at night

Other eye disorders

Have you ever been diagnosed or treated for the following health problems?

Have you ever been diagnosed or treated for the following health problems?

Yes

Allergies

Arthritis

Blood/Lymph

Bronchitis

Cancer

Cholesterol

Diabetes

Digestive

Ears/Nose/Throat

Endocrine (hormonal glands)

Eczema/Rashes

Fatigue

Fevers

Genitourinary (reproductive or urinary)

High Blood Pressure

Integumentary (Skin)

Kidney

Muscle/Bone

Neurological

Psychological

Respiratory

Sinus

Throat Infections

Thyroid

Unusual weight losses/gains

Free Text

Please be advised if you are using insurance coverage for today's visit, this is a contract between you and your insurance company...not Professional Vision Services.

Free Text

The information in this confidential case history form is critical to the evaluation of your vision and health.

Signature

Upload File

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.