Heartland
Optical
Call us today to schedule
your appointment:
(402) 476-3311
1012 North 27th Street | Lincoln, NE 68503
EMERGENCY
APPOINTMENTS AVAILABLE
Patient Forms
To help speed up your next visit, please fill out the following, applicable, forms before you visit our office.
Want to request an appointment? Click here to schedule your appointment.
Wondering if Heartland Optical accepts your vision insurance plan? Click here to view our accepted vision insurance plans.
The following forms are available for your convenience. Please fill them out and submit them before your appointment:
Tell Us About Yourself
First Name:
Last Name:
Address:
City:
State:
ZIP:
Personal Information
Home Phone:
Cell Phone:
Email Address:
Date of Birth:
Gender:
Occupation:
Employer Name:
Home Phone:
Cell Phone:
SSN:
Billing Information
Is your billing address the same as listed?
If you answered no, please fill out your billing address.
Address:
City:
State:
ZIP:
Personal Information Continued...
Copyright 2011 Heartland Optical
Medical History
Who may we thank for referring you?
Are any of your family members already patients at Heartland Optical?
If you answered yes, what is that family member's name?
Are you interested in contact lenses?
Have you ever worn contact lenses?
What type of contact lenses have you worn?
Do you have back up glasses for your contact lenses?
What do you normally wear for vision correction?
Do you have a pair of sunglasses?
Do you have a pair of computer only or office only glasses?
Are you interested in laser vision correction?
Do your eyes sting, burn, itch, or feel dry?
If you answered yes, what problems do you experience?
Have you had an eye injury or been diagnosed with cataracts, lazy eye, retinal problems or gluacoma?
If you answered yes, what problems do you experience?
Do you take any eye drops?
If you answered yes, what kind of eye drops do you take?
Who was your last eye doctor?
Who is your primary care physician?
What medications/vitamins do you take?
Do you have any medication allergies?
Does anyone in your family have/had glaucoma, macular degeneration, retinal detatachment, or other retinal disorders? If so, please list them below.
Does anyone in your family have/had diabetes, lupus, cancer, high blood pressure, heart problems, or an auto-immune disease? If so, please list them below.
Do you have a history or headaches, arthritis, asthma, diabetes, high blood pressure, heart problems, inflammatory bowel disease, seizures, thyroid problems? Do you smoke? Are you pregnant? If so, please list them below.
Insurance Provider Information
Insurance Provider Name:
Insurance ID Number:
Insurance Information
Insurance Policy Group:
Are you the primary person on the account?
If you answered no, please fill out the next portion.
First Name:
Last Name:
Address:
City:
State:
ZIP:
Primary Account Holder Information
Home Phone:
Cell Phone:
Date of Birth:
Gender:
