New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Pena- Greenwood, Janet Dr. Cadena, Linda Dr. Pena- Saratoga, Dr. Dr. Cadena- Greenwood, Dr. Dr. Cadena- Saratoga, Dr Dr. E. Perez-Greenwood, Elizabeth Dr. E.Perez- Saratoga, Elizabeth Dr. Ryan-Greenwood, Casey Dr. Pena, Janet	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None 5-DNU 932436696-DNU AARP Aetna Aetna-HMO-Exam Only-DNU Aetna US HealthCare-DNU Always Care Benefits Attn: Vision Claims Always Care Benefits, Inc.- DNU ALWAYS VISION NVA/ STARMOUNT Amerigroup-DNU Anthem APWU Health Plan Avesis-DNU Avesis Claims Dept BAC Bcbs-DNU BCBS Highmark C/O CMV-DNU BCBS Highmark C/O CMV-DNU BCBS of Kansas Berkeley Eye Institute Block Vision of Texas (AmeriGroup) Blue Cross-DNU Blue Cross Blue Shield of Texas Boon-Chapman Cc Metro Ministries CHRISTUS Health Plan Medicaid & CHIP Attn: Claims Dept Christus Spohn Health Network cigna Cigna-DNU Cigna-DNU CIGNA-DNU CIGNA-DNU Cofinity-Mi-DNU Cole Managed Vision-DNU Cole Managed Vision-DNU Colonial Penn Life Insurance Company Core Source Ins. Core Source Ins.-DNU Corpus Christi Dental Discount-DNU DAVIS VISION DAVIS VISION-DNU Elementis Chromium Elementis Chromium-DNU Entrust EYE MED MANAGED CARE CLAIMS-DNU EYE MED MANAGED CARE CLAIMS-DNU EYE MED VISION CARE-VIA ONLINE-DNU EYE MED VISION CARE-VIA ONLINE-DNU EYE MED VISION CARE ASSIGNMENT CLMS-DNU EYE MED VISION CARE ASSIGNMENT CLMS-DNU Eyemed Manual Claims FAXED ONLY-DNU FEP Blue Vision-DNU FEP BLUE VISION-DNU First Administrators First United Methodist Church GEHA Gerber Life Insurance-Secondary Insurance Group Pension Adminstrators Healthselect Healthselect-DNU Humana-DNU HUMANA CLAIMS-DNU Humana Claims Center Humana Gold Ibew Neca LIFE-RE-DNU LIFE-RE-DNU LifeRe Insurance-DNU LifeRe Insurance-DNU Lincoln Heritage Loyal American Life Insurance Mail Handlers Benefit Plan Managed Indemnity MANUAL CLAIMS SENT TO:-DNU MANUAL CLAIMS SENT TO:-DNU MEDICAID TRANSMITTED VIA ONLINE-DNU MEDICAID TRANSMITTED VIA ONLINE-DNU Medical Mutual Medicare- Corrected Claims Medicare- DNU Medicare Advantage Plan Meritain Health Ins. Missionary Medical-Vision Benefits Missionary Medical-Vision Benefits-DNU MUTUAL OF OMAHA Mutual Protective/Medico Life Ins. Comp. Name-DNU Name-DNU Name-DNU Nationwide Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance Nueces County Juvenile Dept NVA NVA PCR and Associates Collections Physicians Health Choice/Claims Dept. Port Aransas ISD Principal-DNU Principal Life Insurance Project Insight-DNU Qualified Medicare Benefits- DNU Safeguard Secure Horizons Sentinel Plan Sherwin Alumina - Davis Vision-DNU Sherwin Alumina - Davis Vision-DNU Spectera- DNU Spectera-DNU SPECTERA/OPTUM VISION SPECTERA/OPTUM VISION CORRECTED CLAIMS Spohn-DNU Spohn Health Network St Mark's Starmount life ins.- Always Vision c/o CMV-DNU Starmount life ins.- Always Vision c/o CMV-DNU State Farm Health Insurance Superior Vision Superior Vision- DNU Superior Vision Svs, Inc.-DNU Superior Vision Svs, Inc.-DNU Texas Comptroler of Public Accounts Texas Medicaid & Healthcare Partnership TML TML IRP Today's Options PFFS Trailblazer Health Enterprises Tricare For Life Tricare Prime- DNU TRS CARE/ AETNA TX YOUTH COMISSION UMR UMR-Payer I.D. 31107 UNICARE UNICARE-DNU United Health Care United Health Care-Medicare Replacement United Health Care Select Vision Benefits C/O CMV- DNU Vision Benefits C/O CMV-DNU VISION BENEFITS of AMERICA-DNU VISION BENEFITS of AMERICA-DNU Vision Service Plan
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:	None 5-DNU 932436696-DNU AARP Aetna Aetna-HMO-Exam Only-DNU Aetna US HealthCare-DNU Always Care Benefits Attn: Vision Claims Always Care Benefits, Inc.- DNU ALWAYS VISION NVA/ STARMOUNT Amerigroup-DNU Anthem APWU Health Plan Avesis-DNU Avesis Claims Dept BAC Bcbs-DNU BCBS Highmark C/O CMV-DNU BCBS Highmark C/O CMV-DNU BCBS of Kansas Berkeley Eye Institute Block Vision of Texas (AmeriGroup) Blue Cross-DNU Blue Cross Blue Shield of Texas Boon-Chapman Cc Metro Ministries CHRISTUS Health Plan Medicaid & CHIP Attn: Claims Dept Christus Spohn Health Network cigna Cigna-DNU Cigna-DNU CIGNA-DNU CIGNA-DNU Cofinity-Mi-DNU Cole Managed Vision-DNU Cole Managed Vision-DNU Colonial Penn Life Insurance Company Core Source Ins. Core Source Ins.-DNU Corpus Christi Dental Discount-DNU DAVIS VISION DAVIS VISION-DNU Elementis Chromium Elementis Chromium-DNU Entrust EYE MED MANAGED CARE CLAIMS-DNU EYE MED MANAGED CARE CLAIMS-DNU EYE MED VISION CARE-VIA ONLINE-DNU EYE MED VISION CARE-VIA ONLINE-DNU EYE MED VISION CARE ASSIGNMENT CLMS-DNU EYE MED VISION CARE ASSIGNMENT CLMS-DNU Eyemed Manual Claims FAXED ONLY-DNU FEP Blue Vision-DNU FEP BLUE VISION-DNU First Administrators First United Methodist Church GEHA Gerber Life Insurance-Secondary Insurance Group Pension Adminstrators Healthselect Healthselect-DNU Humana-DNU HUMANA CLAIMS-DNU Humana Claims Center Humana Gold Ibew Neca LIFE-RE-DNU LIFE-RE-DNU LifeRe Insurance-DNU LifeRe Insurance-DNU Lincoln Heritage Loyal American Life Insurance Mail Handlers Benefit Plan Managed Indemnity MANUAL CLAIMS SENT TO:-DNU MANUAL CLAIMS SENT TO:-DNU MEDICAID TRANSMITTED VIA ONLINE-DNU MEDICAID TRANSMITTED VIA ONLINE-DNU Medical Mutual Medicare- Corrected Claims Medicare- DNU Medicare Advantage Plan Meritain Health Ins. Missionary Medical-Vision Benefits Missionary Medical-Vision Benefits-DNU MUTUAL OF OMAHA Mutual Protective/Medico Life Ins. Comp. Name-DNU Name-DNU Name-DNU Nationwide Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance Nueces County Juvenile Dept NVA NVA PCR and Associates Collections Physicians Health Choice/Claims Dept. Port Aransas ISD Principal-DNU Principal Life Insurance Project Insight-DNU Qualified Medicare Benefits- DNU Safeguard Secure Horizons Sentinel Plan Sherwin Alumina - Davis Vision-DNU Sherwin Alumina - Davis Vision-DNU Spectera- DNU Spectera-DNU SPECTERA/OPTUM VISION SPECTERA/OPTUM VISION CORRECTED CLAIMS Spohn-DNU Spohn Health Network St Mark's Starmount life ins.- Always Vision c/o CMV-DNU Starmount life ins.- Always Vision c/o CMV-DNU State Farm Health Insurance Superior Vision Superior Vision- DNU Superior Vision Svs, Inc.-DNU Superior Vision Svs, Inc.-DNU Texas Comptroler of Public Accounts Texas Medicaid & Healthcare Partnership TML TML IRP Today's Options PFFS Trailblazer Health Enterprises Tricare For Life Tricare Prime- DNU TRS CARE/ AETNA TX YOUTH COMISSION UMR UMR-Payer I.D. 31107 UNICARE UNICARE-DNU United Health Care United Health Care-Medicare Replacement United Health Care Select Vision Benefits C/O CMV- DNU Vision Benefits C/O CMV-DNU VISION BENEFITS of AMERICA-DNU VISION BENEFITS of AMERICA-DNU Vision Service Plan
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:	None 5-DNU 932436696-DNU AARP Aetna Aetna-HMO-Exam Only-DNU Aetna US HealthCare-DNU Always Care Benefits Attn: Vision Claims Always Care Benefits, Inc.- DNU ALWAYS VISION NVA/ STARMOUNT Amerigroup-DNU Anthem APWU Health Plan Avesis-DNU Avesis Claims Dept BAC Bcbs-DNU BCBS Highmark C/O CMV-DNU BCBS Highmark C/O CMV-DNU BCBS of Kansas Berkeley Eye Institute Block Vision of Texas (AmeriGroup) Blue Cross-DNU Blue Cross Blue Shield of Texas Boon-Chapman Cc Metro Ministries CHRISTUS Health Plan Medicaid & CHIP Attn: Claims Dept Christus Spohn Health Network cigna Cigna-DNU Cigna-DNU CIGNA-DNU CIGNA-DNU Cofinity-Mi-DNU Cole Managed Vision-DNU Cole Managed Vision-DNU Colonial Penn Life Insurance Company Core Source Ins. Core Source Ins.-DNU Corpus Christi Dental Discount-DNU DAVIS VISION DAVIS VISION-DNU Elementis Chromium Elementis Chromium-DNU Entrust EYE MED MANAGED CARE CLAIMS-DNU EYE MED MANAGED CARE CLAIMS-DNU EYE MED VISION CARE-VIA ONLINE-DNU EYE MED VISION CARE-VIA ONLINE-DNU EYE MED VISION CARE ASSIGNMENT CLMS-DNU EYE MED VISION CARE ASSIGNMENT CLMS-DNU Eyemed Manual Claims FAXED ONLY-DNU FEP Blue Vision-DNU FEP BLUE VISION-DNU First Administrators First United Methodist Church GEHA Gerber Life Insurance-Secondary Insurance Group Pension Adminstrators Healthselect Healthselect-DNU Humana-DNU HUMANA CLAIMS-DNU Humana Claims Center Humana Gold Ibew Neca LIFE-RE-DNU LIFE-RE-DNU LifeRe Insurance-DNU LifeRe Insurance-DNU Lincoln Heritage Loyal American Life Insurance Mail Handlers Benefit Plan Managed Indemnity MANUAL CLAIMS SENT TO:-DNU MANUAL CLAIMS SENT TO:-DNU MEDICAID TRANSMITTED VIA ONLINE-DNU MEDICAID TRANSMITTED VIA ONLINE-DNU Medical Mutual Medicare- Corrected Claims Medicare- DNU Medicare Advantage Plan Meritain Health Ins. Missionary Medical-Vision Benefits Missionary Medical-Vision Benefits-DNU MUTUAL OF OMAHA Mutual Protective/Medico Life Ins. Comp. Name-DNU Name-DNU Name-DNU Nationwide Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance Nueces County Juvenile Dept NVA NVA PCR and Associates Collections Physicians Health Choice/Claims Dept. Port Aransas ISD Principal-DNU Principal Life Insurance Project Insight-DNU Qualified Medicare Benefits- DNU Safeguard Secure Horizons Sentinel Plan Sherwin Alumina - Davis Vision-DNU Sherwin Alumina - Davis Vision-DNU Spectera- DNU Spectera-DNU SPECTERA/OPTUM VISION SPECTERA/OPTUM VISION CORRECTED CLAIMS Spohn-DNU Spohn Health Network St Mark's Starmount life ins.- Always Vision c/o CMV-DNU Starmount life ins.- Always Vision c/o CMV-DNU State Farm Health Insurance Superior Vision Superior Vision- DNU Superior Vision Svs, Inc.-DNU Superior Vision Svs, Inc.-DNU Texas Comptroler of Public Accounts Texas Medicaid & Healthcare Partnership TML TML IRP Today's Options PFFS Trailblazer Health Enterprises Tricare For Life Tricare Prime- DNU TRS CARE/ AETNA TX YOUTH COMISSION UMR UMR-Payer I.D. 31107 UNICARE UNICARE-DNU United Health Care United Health Care-Medicare Replacement United Health Care Select Vision Benefits C/O CMV- DNU Vision Benefits C/O CMV-DNU VISION BENEFITS of AMERICA-DNU VISION BENEFITS of AMERICA-DNU Vision Service Plan
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

Paper copy has been scanned into patient record and provided to Dr. for review.

MEDICAL HISTORY   Date of Last Eye Exam:  Last Medical Physical:  Family Doctor's Phone #:

                                                  Last Eye Doctor: Dr. Pena Dr. Bhakta  Family Doctor's Name:

POHx/ FOHx:

Please click the tab under "Yes" or "No" to answer questions.

Do you have Diabetes?                     Yes  No   for how many years?  Using medication? Yes  No   Well controlled?: Yes  No

Do you have Hypertension?              Yes  No   for how many years?  Using medication? Yes  No   Well controlled?: Yes  No

Do you have Cholesterol Problems? Yes  No   for how many years?  Using medication? Yes  No   Well controlled?: Yes  No

Last Blood Glucose:  Range:   Doctor who follows your diabetes?: 

How often do you see doctor for diabetes?  3 months 1 month 6 months annually  Are you allergic to medications? Yes  No

If so, which medication?  

Females, check if you are Pregnant/Nursing?         Type of Contact lenses: Soft Hard

Check any of the following that you have had: Cataracts Glaucoma Macular Degeneration Diabetic Retinopathy

Do you wear glasses? Yes  No  Do you wear contacts? Yes  No   Have you had refractive surgery? (Lasik,PRK,RK, etc) Yes  No

Please list any and all medications you are currently taking, including Over the Counter, Homeopathic, Birth Control, or Remedies:


Please list and date all major injuries, surgeries, and hospitalizations you have had:



Review of Systems (ROS):   Do you currently have any problems with:

	YES NO		YES NO		YES NO
Constitutional(fever,weight loss,appetite):		Integumentary(skin conditions/disorders):		Neurological(headaches,migraines,seizures):
Endocrine(thyroid,diabetes):		Ears,Nose,Throat(allergies,sinus,cough,dry mouth):		Respiratory(asthma,emphysema,bronchitis):
Vascular/Endocrine(hypertension,stroke,diabetes):		Gastrointestinal(diarrea,constipation):		Genitourinary(kidney,bladder,genitals):
Bones/Joints(rheumatoid arthritis,muscle pain):		Lymphatic/Hematologic:		Allergic/Immunologic(allergies,bleeding):
Psychiatric(depression,anxiety):

Ocular Review of Systems:             **Please indicate which eye(s)**
     

Do you have or have had

YES NO

Right Left

YES NO

Right Left

Are you sensitive to(check all that apply):

Sudden Vision Loss

Glare/light sensitivity

Smog  Animals  Dust  Pollen  Contact Lens Solution

Double Vision

Tearing/watery

Heaters  Blowers  Air Conditioning  Cigarettes  Contacts

Mucus discharge

Haloes at night

Itching/burning

Redness

Eye pain/discomfort

Floaters

Flashes of light

Loss of side vision

Gritty feeling/dryness

Blurred vision

Do you have a family history of (check all that apply):	YES NO	Relationship to you (parent,sibling,etc)		YES NO	Relationship to you (parent,sibling,etc)
Blindness			Cataracts
Macular Degeneration			Glaucoma
Retinal Disease			Arthritis
Cancer			Diabetes
High Blood Pressure			Heart Disease
Kidney Disease			Thyroid Disease

Social:(this information is strictly confidential,you may discuss this part with the doctor)

Do you drive? Yes  No   Do you use illicit drugs? Yes  No  Do you have visual difficulty driving? Yes  No Do you use tobacco products? Yes  No 

Do you use alcohol products? Yes  No Have you been exposed to any infectious disease? (HIV,STDs,Hepatitis,TB,etc) Yes  No 

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