New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
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:
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:
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:
Employer/School:

Medical History

Medical History: Diabetes, High blood pressure, Heart Disease, Thyroid Disease, Kidney Disease, Arthritis, Asthma, Cancer, Stroke, Seizures, Heart Condition, Other
Ocular History: Glaucoma, Macular degeneration, Cataract, Retinal detachment, Crossed/lazy eye, Injury, Surgery
Injuries, Surgeries, Hospitalizations:
Family Medical History:
Family Ocular History:
General Practitioner:
Pregnant/Nursing:

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Medications (Prescribed):
Over-The-Counter Medications:
Vitamins:
Eye Meds:
Drug Allergies:
Primary Vision Correction:
Last Eye Exam:
Sunglasses?
Type of CLs:
Occupation:
Hobbies:

REVIEW OF SYSTEMS-Please document if you currently have or previously had any of the following:

CONSTITUTIONAL:
EYES:
EAR/NOSE/THROAT:
CARDIO:
RESPIRATORY:
GASTRO-INTESTINAL:
REPRODUCTIVE/URINARY:
MUSCULOSKELETAL:
SKIN:
NEURO:
PSYCH:
ENDOCRINE:
BLOOD/LYMPH:
IMMUNOLOGIC:

SOCIAL HISTORY:

Race:
Ethnicity:
Language
Height: Feet Inches
Weight:
Alcohol:
Tobacco:
Illegal Drugs

Submit Data

After Completing All Forms Submit Data on Final Tab