New Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
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:
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Unknown
Single
Married
Separated
Divorced
Widowed
Child
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Hoang, Bao
Dr. Nwachukwu, Nneoma
Dr. Williams, James
Dr. Ruiz, Mark
Dr. Nguyen, Tram
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
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
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:
None
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:
None
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
What is the reason for your visit?
Do you feel your eyes are changing? (if yes, please explain)
When was your last eye exam?
Who was your last eye doctor?
Do you have dry eyes or allergies?
How did you hear about us?
Unknown
Insurance
Friend/Family
Website/Internet
Yellow Pages
Walk-by/Drive-by
Occupation / Employer:
Hobbies:
How many hours a day do you use a computer?
Do you wear contact lenses?
If no, are you interested in contact lenses?
Yes
No
If yes, what type of contacts do you wear?
Daily Wear
Extended Wear
Soft
Disposable
Hard
Gas Permeable
Astigmatism or Toric
Bifocal
Monovision
Mutlifocal
What brand of contacts do you wear?
Acuvue Advance
Acuvue Oasys
Air Optix Aqua
Air Optix Night and Day
Biofinity
Soflens
Other
How often do you replace your contacts?
Monthly
Daily
Every two weeks
Yearly
What brand of solution do you use?
Bio True
Boston Original
Boston Simplus
Clear Care
Optifree Moist
Renu
How long have your contacts been on your eyes?
Do you have any complaints about your current contacts?
Primary Care Physician:
Telephone #:
Please list any surgeries you have had:
Fax #:
Please list any ocular surgeries you have had
List any medications you are taking:
Are you allergic to any medications? (if yes, please list them)
Have you ever been diagnosed with any of the following?
Cataracts
Macular Degeneration
Glaucoma
Turned Eyes
High Blood Pressure
Diabetes
Has anyone in your family ever been diagnosed with any of the following? (if so please state their relationship to you)
yes
no
Cataracts
Macular Degeneration
Glaucoma
Turned Eye
High Blood Pressure
Diabetes
NOTES/SOCIAL HISTORY
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