New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
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:
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

After Completing All Forms Submit Data on Final Tab