Home » Contact Us » Patient Form

Patient Form

  • Millard Vision Center

    15340 Weir Street
    Omaha, Nebraska 68137
    Phone: 402-932-9222
    www.millardvisioncenter.com

    Welcome to our office. Please complete this form to the best of your knowledge.
    The information you give will enable us to provide you with total eye care for you and your family.
  • GENERAL INFORMATION

  • BILLING INFORMATION (if different from patient )

  • INSURANCE

  • I do hereby authorize the release of any medical information necessary to process all claims, and request payment of any medical benefit be paid to Millard Vision Center.

    I have received the form “Joint Notice of Privacy Practices” and give my permission to MILLARD VISION CENTER to use and disclose my health information in accordance with the notice provided.
  • Your email is just for Millard Vision Center use, it will never be distributed to anyone.
  • MEDICAL HISTORY

  • MedicationDosage 
    Add a new row
  • NoYes
    Heart Disease
    Congestive Heart Failure
    Vascular Disease
    Stroke
    High Blood Pressure
  • NoYes
    Osteoporosis
    Arthritis
    Chronic Low Back Pain
    Fibromyalgia
  • NoYes
    Osteoporosis
    Arthritis
    Chronic Low Back Pain
    Fibromyalgia
  • NoYes
    Sleep Apnea
    Bronchitis
    Asthma
    Emphysema
  • NoYes
    Rosacea
    Herpes Zoster/Shingles
    Eczema
    Herpes Simplex/cold sores
    Psoriasis
    Skin Cancer
  • NoYes
    Headaches
    Seizures
    Dizziness / Vertigo
    Multiple Sclerosis
  • NoYes
    Crohn's Disease
    Celiac Disease
    Colitis
    Ulcer
  • NoYes
    Diabetes
    Thyroid Dysfunction
    Hepatitis
  • NoYes
    Drug Addiction
    Alcohol Addiction
    Depression
  • NoYes
    Herpes
    Prostate Disease/Cancer
    Kidney Disease
  • NoYes
    Bleeding problems
    Anemia
    Leukemia/Lymphoma
    Jaundice
  • NoYes
    Do you use alcohol
  • FAMILY HISTORY

    Please note any family (parents, grandparents, siblings, children, living or deceased) for the following conditions:
  • NoYes
    Cancer
    Diabetes
    High Blood Pressure
    Thyroid Disease
    Heart Disease
    Thyroid Disease
    Stroke
  • NoYes
    Cataracts
    Macular Degeneration
    Glaucoma
    Cross Eye/Lazy Eye
    Amblyopia
    Retinal Detachment
    Blindness
  • ConditionRelationship 
    Add a new row
  • ConditionRelationship 
    Add a new row
  • THANK YOU FOR CHOOSING MILLARD VISION CENTER !