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 different? If different, please fill out below.
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:

Tertiary

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

Exam type
Reason for your visit:
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:

Family Med History:
 None  Diabetes  High Cholesterol  Hypertension       Other 
Family Eye History:
 None  Macular Degeneration  Cataracts  Glaucoma   Other 
Social History
Last Eye Doctor
Primary Care Physician:
Last Medical Exam with PCP:
Contagious Disease Exposure:
Smoking Status
Preferred Language
Race
Ethnicity
No Known Drug AllergiesNo Known Medications

Submit Data

After Completing All Forms Submit Data on Final Tab