New Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address:
City:
State/ZipCode
TX
AL
AK
AZ
AR
CA
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. Maanum, John
Misc/Guardian
Billing Information
Is The Billing Address different?
If different, please fill out below.
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address
City
State
ZipCode
TX
AL
AK
AZ
AR
CA
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
AETNA
BLUE CROSS
CASH
Cigna
Davis Vision
EYEMED
MEDI-CAL
MEDICARE
MES
New Insurance
New Insurance
NVA
PRIVATE INS.
Safeguard
SPECTERA
United Health Ins
VSP Choice
VSP EXAM PLUS ALLOWANCE
VSP HEALTHY FAMILY
VSP REGIONAL NETWORK
VSP Signature
VSP STATE OF CA
VSP VALUE 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
AETNA
BLUE CROSS
CASH
Cigna
Davis Vision
EYEMED
MEDI-CAL
MEDICARE
MES
New Insurance
New Insurance
NVA
PRIVATE INS.
Safeguard
SPECTERA
United Health Ins
VSP Choice
VSP EXAM PLUS ALLOWANCE
VSP HEALTHY FAMILY
VSP REGIONAL NETWORK
VSP Signature
VSP STATE OF CA
VSP VALUE 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:
Tertiary
Insurance Information
Insurance Name:
None
AETNA
BLUE CROSS
CASH
Cigna
Davis Vision
EYEMED
MEDI-CAL
MEDICARE
MES
New Insurance
New Insurance
NVA
PRIVATE INS.
Safeguard
SPECTERA
United Health Ins
VSP Choice
VSP EXAM PLUS ALLOWANCE
VSP HEALTHY FAMILY
VSP REGIONAL NETWORK
VSP Signature
VSP STATE OF CA
VSP VALUE 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
Exam type
Eye exam - glasses
Eye exam- contact lenses
Eye exam - medical
Office visit - red eye
Contact lens follow up
Rx check
Glaucoma eval
Glaucoma F/UP
Dry eye evaluation
Dry eye follow up
Reason for your visit:
annual eye health check
visual blur through current SRx
Visual blur - distance
Needs new contacts
Visual blur - near
Visual blur - both
Red Eye
Headaches
Injury
Annual check for cataracts
Flashing lights
Increase in floaters
Glasses broke
Glaucoma exam
Dry eyes
Other: See notes
Ocular History
None
Cataracts
Glaucoma
Macular Degneration
Injury/Surgery
Other
Medical History
None
Hypertension
High Cholesterol
Diabetes
Other
Systemic Medications:
None
Eye Medications:
None
Drug and Environmental Allergies:
None
Sulfa
Penicillin
Erythromycin
Iodine
Codeine
Pollen/ Dust
Animal Dander
NKDA
Family Med History:
None
Diabetes
High Cholesterol
Hypertension Other
Family Eye History:
None
Macular Degeneration
Cataracts
Glaucoma Other
Social History
Social Hx: Denies any tobacco, alcohol and drug use
Tobacco User
Alcohol Use: Social
Alcohol Use: Constant
Last Eye Doctor
Primary Care Physician:
Last Medical Exam with PCP:
Unknown
less than 1 year
1 year
2-3 years
4 or more years
Never
Contagious Disease Exposure:
None
Gonorrhea
HIV/Aids
Syphillus
Hepatitis
Smoking Status
Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke)
Former smoker (no longer smokes)">Former smoker (no longer smokes)">Former smoker (no longer smokes)
Current some day smoker (not daily)
Light smoker (<10 cigs/day)
Heavy smoker (>10 cigs/day)
Smoker (current status unknown)
Smoker (current status unknown)
Unknown if ever smoked
Other
Preferred Language
English
Spanish
Other
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other Race
Patient Declined to Specify
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
No Known Drug Allergies
No Known Medications
Submit Data
After Completing All Forms Submit Data on Final Tab