Annual Patient History Update
If you have been a patient at Bethel Vision Center in the pas, then please fill in the data on this form. If we do not find you in our records we will ask you to fill out a NEW PATIENT form
before a doctor can see you.
You may enter dates by clicking on the calendar icon next to the data field or you may enter a date directly into the textbox. If you enter the date into the text box
it must be in the form MM/DD/YYYY. If you see a date of 02/18/1867 it means you have not entered a date in that field.
SSN if you enter it must be in the from 999-99-9999.
First Name and Last Name are required.
WHen you are done filling in the data, press the Save button. If you have made any errors a pop up message will list them. You can then correct the named item. Once your data
is correct and you press the Save button, a popup message will indicate success.
If you wish to print a copy of your data, please do so after saving it first.
Once you save the data it cannot be edited. If you wish to edit after saving, then press the Home button and then click the New Patient button again. If you do this within
20 minutes of the time saved it, you will be able to see your previously entered data and change it. You can then save it again. This will send multiple copies of your
information to the doctor.
Please provide information for both your Medical health insurance and your Vision insurance. Vision Insurance is mainly a wellness benefit and is provided to
help reduce your costs for preventive eye care while the Medical insurance exists for more serious eye problems.
Patient Medical History
Please let us know the date of your last physical exam and update us about your medications, allergies to medications, major illnesses, injuries or surgeries.
Do you currently have any problems in the following areas? If yes, please check the appropriate box.