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 Employment Status
Marital Status Employer/School
Misc/Guardian

Billing Information

Is The Billing Address the Same?
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?     
______________________________________________________________________________________________________________________________________________________
Please list any medications you are currently taking:


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

What medications are you allergic to, if any:


(Women) Are you pregnant or nursing?
______________________________________________________________________________________________________________________________________________________

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

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REVIEW OF SYSTEMS
DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

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)?


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)

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): 
______________________________________________________________________________________________________________________________________________________

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