Simpson and Mann Optometry

Services
Conditions Treated
Patient Center
- Online Forms
  - Infant & Preschool - English
  - Infant & Preschool - Spanish
- Insurance and Payments
About Us
- Meet the Optometrist
- Testimonials
Resources
- Frames
- Blog
Contact
- Appointment Request

(909) 986-0918

Simpson and Mann Optometry

Services
Conditions Treated
Patient Center
- Online Forms
  - Infant & Preschool - English
  - Infant & Preschool - Spanish
- Insurance and Payments
About Us
- Meet the Optometrist
- Testimonials
Resources
- Frames
- Blog
Contact
- Appointment Request

(909) 986-0918

Home

Patient Center

Online Forms

Infant & Preschool - English

Infant & Preschool - English

Name*

Birth Date

Gender

Male Female

Age

Home Address

City

State

Zip

Home Phone *

Email *

Social Security #

Mom’s First and Last Name

Occupation

Work Phone

Social Security #

Dad’s First and Last Name

Occupation

Work Phone

Social Security #

Names and Ages of Family Members Living at Home

Referred By

Physician’s Name and Phone

Insurance

Vision:

VSP

MES

Other

Insured By

Mother Father

Major Medical

AETNA

MEDI-CAL

Healthy Families

Other

Insured By

Mother Father

Patient History

No Problem-General Check Up Rubs Eyes Excessively Squint Eyes Eyes Turn In Eyes Tear Excessively Eye or Head Injury Eyes Turn Out 2nd Opinion Doctor Referred Red/Crusty Eyes Visual Problems in Other Family Members Blurred Vision Other

If Other, Please Indicate

My Child Is

Natural Adopted Foster Other

Pregnancy History

Less Than 7 mos. 7-8 mos. 8-9 mos. Over 9 mos.

During pregnancy of this child, which, if any of the following occurred:

Toxemia Injury by Fall Severe Illness Trauma Smoking Prescribed Medication Use of Alcohol Use of Drugs Little Obstetrical Care

Please explain

Type of Delivery

Natural Caesarian Forceps/Vacuum Anesthesia Other

Were there any problems during the delivery?

Yes No

If Yes/Please Explain

Child’s Birth Weight

Lbs

Ozs

Is your child currently taking any medications?

Yes No

If “Yes”, please list and note purpose

History of: (please note when or to what)

High fever Ear infections Epilepsy or seizures Medication allergies Allergies

Patient eye history

Yes No

Yes, at age

Compliance?

Patching

Yes No

Yes, at age

Compliance?

Vision Therapy

Yes No

Yes, at age

Compliance?

Eye Surgery

Yes No

Yes, at age

Compliance?

Has any blood relative had: (list relationship to child)

Yes No

Cataracts

Yes No

Diabetes

Yes No

Glaucoma

Yes No

Lazy Eye

Yes No

Heart Disease

Yes No

High Blood Pressure

Yes No

Retinal Problems

Yes No

Eye Turn

Yes No

Learning Disability

Yes No

Developmental Stages

EARLY LATE NORMAL UNSURE

Head Control

EARLY LATE NORMAL UNSURE

Hand Grasp

EARLY LATE NORMAL UNSURE

Sits w/Out Support

EARLY LATE NORMAL UNSURE

Walks Unaided

EARLY LATE NORMAL UNSURE

Scribbles Spontaneously

EARLY LATE NORMAL UNSURE

Combines 2 Different Words

EARLY LATE NORMAL UNSURE

Copies Circle

EARLY LATE NORMAL UNSURE

Rides Tricycle

EARLY LATE NORMAL UNSURE

Knows Colors

EARLY LATE NORMAL UNSURE

List all previous evaluation done on your child

DATE(S)

TYPE OF EVALUATION

RESULTS/TREATMENT/INTERVENTION

Names and addresses of individuals or agencies that you wish to receive the results of our exam

Further Comments

PAYMENT TERMS: We are happy to assist you in the filing of your insurance claim. If your insurance will not pay the anticipated amount, or your insurance pays you directly, we ask that you pay the balance. Office policy calls for payment at the time of service.

If eyewear or contact lenses are to be ordered, a minimum 50% deposit is requested and the balance is due upon delivery. We accept cash, personal checks, Visa and Mastercard. A monthly rebilling fee of $5 is added to all accounts with unpaid balances after 30 days.

I have read and agree to all the provisions of the office financial policy
I have received/reviewed a copy of the health care information privacy policy for Simpson and Mann Optometry

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Visit our Office

--mi

Address

9675 Monte Vista Ave # B
Montclair, CA 91763

Contact Information (909) 986-0918

Hours of Operation

Monday

8:00 am - 5:00 pm

Tuesday

8:00 am - 5:00 pm

Wednesday

8:00 am - 5:00 pm

Thursday

8:30 am - 6:00 pm

Friday

8:00 am - 5:00 pm

Saturday

By Appointment Only

Sunday

Closed

Simpson and Mann Optometry

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