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Doctors Vision Center corporate office is located in Rocky Mount, North Carolina. If you need assistance, email us.

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Your questions will be forwarded to the Doctors Vision Center eye care professional nearest you. We will respond within 24 hours.





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Emergency Eye Services

Our medical professionals are available 24 hours a day/7 days a week. Learn More

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We Welcome New Patients.

Save time when visiting Doctors Vision Center by completing your new patient forms online. As with any professional medical office, we will need some initial information and your medical history to set you up as a new patient.  Prior to your visit, please fill out these forms, print and bring them with you to your appointment.


Patient and Responsible party information

First name *
 Last name *
 Nickname *

Address *

City *

State *

Zip

Home/Work #

Employer
 Soc sec #

Birthdate

Sex
 Male Female
Martial status
 S M D W
Occupation *

Are you member of Doctors Vision Center Group Vision Plan?
 Yes, I Am Yes, My Family Is No Don`t Know

If yes, Company name

Family member who has Group Vision Plan
 Self Parent Spouse

Email *

How did you hear about our office?

Do you have any questions about dry eyes, laser corrective surgery, vision therapy or any other medical concerns? If so, please list:

Insurance information

Primary Insurance Co.

Policy holder

Relation to patient
 Self Spouse Child Other 		Secondary Insurance Co.

Policy holder

Relation to patient
 Self Spouse Child Other

Payment information

Your method of payment *
 Cash Check Credit Card

Acknowledgment

1. Payment policy: payment in full is expected at the time professional services are rendered and/or materials are ordered. We are happy to file for insurance payment when applicable. A charge of 1.5% per month will be added to all accounts 30 days past due 

2. If insurance is filed on my behalf, I authorize my insurance benefits to paid directly to Doctors Vision Center 

3. I agree that unless Doctors Vision Center and my insurer have a prior agreement, I am personally responsible for all non-covered services, co-pays and deductibles 

4. I authorize the release of medical information to insurance carriers or other physicians if it is deemed necessary by my optometrists for financial or consultative purposes 

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Patient Medical History Form

Name *

Birthdate *

Sex *
 Male Female
Race *
 Cauc. AA Hisp Orient.

Date *

Family Medical Doctor

Last Eye Doctor

Last Exam

Any problems with driving (distance) vision?
 No Yes
Reading (near) vision?
 No Yes

What type of eyeglasses do you currently wear?
 None SV Bifocals Progressive OTC Readers

Do you wear CL`s?
 No Yes
If yes, what kind?
 Soft RGP DW EW Other:

Do you have problems with night vision?
 Yes No
Are you interested in seeing without glasses or contact lenses?
 No Yes

Reason for visit (location, quality, severity, duration, timing, context, modifying factors, assoc. signs, etc.)

Ocular meds

Systemic meds

Drug allergies

Past Medical, Family, Social and Ocular History

Medical History / Review of Systems

 Year of DX Family
 Diabetes/Endocrine  Yes
 High Blood Pressure  Yes
 Heart Disease  Yes
 Lung Disease (asthma, emphysema)  Yes
 Ear, Nose, Throat (allergies)  Yes
 Blood/Lumphatic
 Thyroid Disease
 GI Disease (ulcers, acid reflux)
 Arthritis
 Kidney, Bladder, Genital
 Neurological
 Mental (depression, anxiety)
 Infectious Disease (HIV, hepatitis)

Surgeries (list)

Constitutional: are you well today?  Yes No
Female: are you pregnant?  Yes No

Ocular History

 Year of DX Family
 Redness, discomfort, dry or watery
 Glaucoma  Yes
 Cataracts  Yes
 Macular Degeneration  Yes
 Blindness  Yes
 Lazy Eye/Eye Turn  Yes
 Retinal Disorders  Yes
 Eye Injuries
 Eye Surgeries  Yes

Others (list)

Social History

Martial Status:  Single Married Divorced/Widowed
Do you live alone?  No Yes Nursing Home



Current occupation:

Any special occupation or avocational vision needs for work or hobbies?

How many hours do you use a computer today?  None 1-3 hours 3+ hours
Do you notice problems with computer use?  No Yes
Are you interested in trying contact lenses?  Yes No

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