New Patient Form

After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information

Title:	First	Last
MI:	Suffix:	Nickname:

Address:

Apt/Suite #:

City:

State:

Zip Code:

Home Phone:	Work Phone:
Other Phone:	Alerts:
Cell Phone:	Contact Method:
SSN	Email
Birthday	Occupation
Sex Male Female F	Employment Status Employed Full-Time Student Part-Time Student
Marital Status	Employer/School
Misc/Guardian

Billing Information

Is The Billing Address the Same? Yes

Title:	First:	Last:
MI:	Suffix:

Address:

Apt/Suite #:

City:	State:	Zip Code:
Home Phone:	Work Phone:

Medical History

VISUAL HISTORY:
How long since last eye exam?

Have you ever worn contact lenses? YesNo
______________________________________________________________________________________________________________________________________________________
Please list any medications you are currently taking: Or check here if none

Please list all eyedrops you use (OTC and Rx):

What medications are you allergic to, if any: Or check here if none

(Women) Are you pregnant or nursing?Yes No
______________________________________________________________________________________________________________________________________________________

If answers are left blank below, it will be assumed to be a negative response.

Do you have a history of any of the following?

Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Glaucoma
Macular Degeneration
Retinal Detachment
Eye Injury
Eye Surgery
List any eye surgeries:

Are you currently experiencing any of the following?

Double Vision
Eyes "hurt" or "tired"
Irritated Eyes
Flashing lights
Dry Eyes

General:
Ear/Nose/Throat:
Skin:
Cardiovascular:
Respiratory:
Musculoskeletal:
Psychiatric:
Gastrointestinal:
Endocrine:
Blood/Lymph:
Neurological:
Genitourinary:
Immune:

______________________________________________________________________________________________________________________________________________________

FAMILY HISTORY
Do you have any history of the following in any FAMILY members (parents, grandparents, siblings, children)?
Family history is unknown/adopted

Condition	Yes Or No	Relationship To Patient
Blindness
Eye turn (Strabismus)
Glaucoma
Macular Degeneration
Retinal Detachment Or Disease

Condition	Yes Or No	Relationship To Patient
Cancer
Diabetes
Heart Disease
High Blood Pressure
Thyroid Disease
Other Inherited Disease

If yes, what disease?

Lifestyle

New Patients Only
LIFESTYLE:
Very Important! New patients only. Who may we thank for referring you to our office? Name of friend or relative:

If not referred, how did you choose our office?

Do you..... (check box if your answer is yes)
...have trouble with tilting your head if you have bifocals? ...think you might benefit from thinner, lighter lenses? ...have interest in an in-office trial of the latest contact lens designs? ...play recreational sports/outdoor activities? ...have problems with glare or reflections? ...have prescription sunglasses you use while driving? ...want information on Laser Vision Correction surgery? ...participate in a Flex Spending Account? ...have children? ...have family members in need of eye care?
What sports, hobbies, or activities do you enjoy?

I have read and understand, to the best of my knowledge, the above information. I certify that all statements are truthful and accurate. I authorize the release of any information
concerning my (or my child's) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I understand that I am
financially responsible for any service considered non-covered, any deductibles and/or co-payments as well as any servie denied due to non-participating provider.

Patient or Parent or Guardian signature: (type name here):
______________________________________________________________________________________________________________________________________________________

New Patient Form

Patient Information

Billing Information

Medical History

Lifestyle

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