New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Miss Rev.

Address:
City:		State/ZipCode	CA TX AL AK AZ AR CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Germundsen, Kevin Dr. Sekhon, Janay Dr. Arboleda, Linda Dr. G ov, Dr. Kirk, Michelle Dr. S ov, Dr. A ov, Dr. Kirk ov,	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Miss Rev.

Address

City	State	ZipCode
	CA TX AL AK AZ AR CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP Aetna Aetna Discount Affiliated Doctors of OC Anthem APWU HEALTH PLAN Arta Health Net Beechstreet Blue Cross of California Blue Cross/Blue Shield Blue Shield of California CARPENTERS TRUST Cigna Comp Benefits Definity Health Delta Health Systems Edinger Medical Group Eyemed Eyemed Discount FIRST CHOICE CCN Golden West Great-West Guardian Health Health Net HealthPartners National Choice HMA Humana LHI Managed Benefit Adminstrators Medical Eye Services Medicare MES% Monarch Healthcare MSI New Insurance NGS Optum Health Vision Pathway Principal private health insurance Prospect Med Grp Quality Benefits Regence of Blue Shield Retail Clerks Safeguard SMA Insurance Administrators Smile Saver So. Cal. Pipe Traders Spectera, Inc. Superior Vision The ILWU-PMA THE ILWU-PMA TriCare Tricare Prime TriWest United Health Care USI Admin. Vision Plan of America Vision Service Plan
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None AARP Aetna Aetna Discount Affiliated Doctors of OC Anthem APWU HEALTH PLAN Arta Health Net Beechstreet Blue Cross of California Blue Cross/Blue Shield Blue Shield of California CARPENTERS TRUST Cigna Comp Benefits Definity Health Delta Health Systems Edinger Medical Group Eyemed Eyemed Discount FIRST CHOICE CCN Golden West Great-West Guardian Health Health Net HealthPartners National Choice HMA Humana LHI Managed Benefit Adminstrators Medical Eye Services Medicare MES% Monarch Healthcare MSI New Insurance NGS Optum Health Vision Pathway Principal private health insurance Prospect Med Grp Quality Benefits Regence of Blue Shield Retail Clerks Safeguard SMA Insurance Administrators Smile Saver So. Cal. Pipe Traders Spectera, Inc. Superior Vision The ILWU-PMA THE ILWU-PMA TriCare Tricare Prime TriWest United Health Care USI Admin. Vision Plan of America Vision Service Plan
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

MEDICAL, PERSONAL AND FAMILY HISTORY:

      What is the reason for your visit today?    Please list all eyedrops you are currently using. 

      Do you have any medical conditions (ie: Arthritis,Diabetes,COPD,Cancer,Heart Disease,Hypertension)?: 

      Do your blood relatives have any medical conditions (ie: Arthritis,Diabetes,COPD,Cancer,Heart Disease,Hypertension)?: 

      Do you have any eye-related conditions or surgery: (ie: Cataract,Glaucoma,Lasik,Retinal Detachment,Lazy Eye)?   

      Do you have any blood relatives with eye health related conditions: (ie. Cataract, Glaucoma,Lasik,Retinal detachment, lazy eye)?  

     Please list any allergies you have.   Please list all medications your are currently taking.  

     No known drug allergies     No current medications

Submit Data