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:
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Medical History
Contacts?
yes
no
Other
2018 Contact lens brands
1-Day Acuvue Moist
1-Day Acuvue Moist for Astigmatism
1-Day Acuvue Moist Multifocal
2 Clear XC
2-Clear 1 Day / Clearsite
2-Clear Premium
2-Clear Toric
Acuvue 1-Day Define
Acuvue 2
Acuvue Oasys 1-Day for Astigmatism
Acuvue Oasys 1-Day with Hydralux
Acuvue Oasys for Astigmatism
Acuvue Oasys Multifocal
Acuvue Oasys with HydraClear Plus
Acuvue TruEye 1-Day
Air Optix Aqua
Air Optix Aqua Multifocal
Air Optix Colors
Air Optix for Astigmatism
Air Optix for Astigmatism
Air Optix Night & Day Aqua
Air Optix plus HydraGlyde
Air Optix plus HydraGlyde for Astigmatism
Alden Colors
AquaClear
AquaClear Toric
Avaira
Biofinity
Biofinity Energys
Biofinity Multifocal
Biofinity Sphere XR
Biofinity Toric
Biofinity Toric XR
Biomedic Toric
BioTrue ONEday
BioTrue ONEday for Astigmatism
BioTrue ONEday MF
C-Vue Bifocal
Dailes Aqua Comfort Plus
Dailes Aqua Comfort Plus Multifocal
Dailies Aqua Comfort Plus Toric
Dailies Total 1
Dailies Total 1 Multifocal
Focus Dailies
Focus Dailies Toric
Frequency 55
Frequency 55 Toric
Frequency 55 Toric SR
Fresh 30
Fresh Day
Fresh Day for Astigmatism
Fresh Day Multifocal
Freshlook Multifocal
Freshlook Colorblends
Freshlook Dimensions
Freshlook ONE DAY Color
Hydrasoft DW
Hydrasoft EW
Hydrasoft Toric DW
Hydrasoft Toric EW
Illusions Colors
MyDay
MyDay Toric
Preference Spherical
Proclear 1 Day
Proclear 1 Day Multifocal
Proclear Compatible
Proclear Multifocal Monthly
Proclear Toric Monthly
Proclear Toric Multifocal Monthly
Proclear Toric XR
Purevision
Purevision 2
Purevision 2 Multi-Focal for Presbyopia
Purevision 2 Toric for Astigmatism
Purevision Multifocal
Purevision Toric for Astigmatism
SofLens 38
SofLens 66 Toric for Astigmatism
SofLens Daily Disposable
SofLens Daily Disposable for Astigmatism
SofLens Multifocal
Synergeyes A
Synergeyes Clearcone
Synergeyes Duette
Synereyes KC
Synergeyes Ultrahealth
Ultra
Ultra for Astigmatism
Ultra for Presbyopia
United Contact Lens Toric
Vertex Toric
Vertex Toric XR
Other
Patient since
Glaucoma suspect?
Needs Profile done
yes
no
low risk
moderate risk
high risk
glaucoma
Pt. referred through HMO
Other
How referred to us?
Friend/family/co-worker
Insurance list
Googled us
Instagram
Yelped us
Walked by
Other
Other
How did your research us?
didn't research online
Website
Facebook
Yelp!
Google
Instagram
Bing
Yahoo
Other
Hobbies
Fishing
Golf
hiking
movies
Reading
surfing
traveling
quilting / knitting
Other
Patient Medical History
No Significant History
Allergies
Arthritis
Asthma
Cancer
Diabetes
Gout
Herpes
Hypertension
Hypercholesterolemia
Migraines
Pregnant
Thyroid Abnormal
Other
Ocular History
None
Abrasion
Blind Eye
Blepheroplasty
Cataract - OU
Cataract - OD
Cataract - OS
Conjunctivitis
Dry
Glaucoma
IOL - OU
IOL - OD
IOL - OS
Itchy
Lazy Eye
Metal in Eye
Ptosis
Retinal Detach
Sandy
Sting
Watery
Other
CHIEF COMPLAINT
burning
Diabetic eye exam
distance blurry without glasses
dry eyes
itching
loss of vision
injury to eye
near vision blurry
needs new glasses
pain in eye
red eye
stinging
vision blurry distance and near
wants to be fitted for contacts
pt denies head turn/tilt, squinting or the closing of one eye while performing visual tasks
no headaches noted
Other
Patient Medical History
Family Medical History: -
Family Medical History Unknown
No Significant History
Arthritis
Cancer
Diabetes
Heart Disease
Hypertension
Hypercholesterolmia
Thyroid Abnormal
Other
Family Ocular History:
No Significant History
Amblyopia
Cataracts
Glaucoma
Lazy Eye
Macular Degeneration
Retinal Detachment
Other
Review of Systems:
Ocular Medication
Allergies: -
No known drug allergies
Systemic medication -
No current medications
Submit Data
After Completing All Forms Submit Data on Final Tab