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 the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Insurance

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 Insurance

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:

Other Vision or Medical Insurance

Please list any secondary vision coverage or supplimental medical coverage
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:

Chief Complaint


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

Chief Complaints
Reason For Visit: Exam Type:
Patient Status: Last Eye Exam:
Other Complaints / Notes:

Patient Past Ocular History
Eye Infections, Diseases, Injuries, Surgeries:
Eye Related Medical Conditions:
Eye Meds/Drops Currently Used:

Primary Vision Correction
Primary Vision Correction Used: Used:

Age of Current Glasses: Planning to get new glasses?

Type of CLs worn: Wearing CL's:
Lens Care Solution: Replace Contact Lenses How Often?:
Extended Wear Use? : Extended Wear Compliance:
Overall CL Compliance:

NOTES:


Patient Information


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

Patient Medical History
Please enter your medical history below:


Injuries, Surgeries, Hospitalization:

Last Physical: Primary Care Physcian: Notes:

Systemic Meds:Drug Allergies:
Over The Counter / Non Rx:Vitamins:

Family Ocular History
Glaucoma: Cataracts: Diabetes:
Macular Degeneration: Retinal Detachment: Other:
Additional Notes:

Social History
Occupation: Visually Demanding Activities/Hobbies: Employer:
Referred By:

Smoking Status: Alcohol: Drugs/Narcotics: HIV ?:
Details:


Submit Data

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