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
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:

Medical Insurance

Insurance Information

Insurance Name:	None Advantica Aetna Amacore Vision AmeriChoice Ancillary Care Services Barter Acct Block Vision Blue Cross/Blue Shield Cigna Comp Benefits Coventry Health Care Davis Vision EyeMed First Health First Look Vision Galaxy Health Network Humana Humana Vision Medicare MES Vision Metlife Safeguard Multiplan National Vision Administrators Opticare Oxford Health Plans PacifiCare PHCS Premier Provider Network, Inc Principal Insurance Seton Health Plan Superior Vision Texas True Choice Tricare United Health Care United Healthcare Vision USA Managed Care Vision Benefits of America Vision Care Plan Vision USA VSP
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:

Vision Insurance

Insurance Information

Insurance Name:	None Advantica Aetna Amacore Vision AmeriChoice Ancillary Care Services Barter Acct Block Vision Blue Cross/Blue Shield Cigna Comp Benefits Coventry Health Care Davis Vision EyeMed First Health First Look Vision Galaxy Health Network Humana Humana Vision Medicare MES Vision Metlife Safeguard Multiplan National Vision Administrators Opticare Oxford Health Plans PacifiCare PHCS Premier Provider Network, Inc Principal Insurance Seton Health Plan Superior Vision Texas True Choice Tricare United Health Care United Healthcare Vision USA Managed Care Vision Benefits of America Vision Care Plan Vision USA VSP
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

Referred By:

Insurance Friend/Family Website/Internet Yellow Pages Walk-by/Drive-by

Referring Doctor:

Family Patients:

Hobbies:

Interested In Contact Lenses?

Yes No

Ever Worn Contact Lenses?

Yes No

Type of CLs worn in past:

Disposables Extended Wear Gas Permeables Gas Perm Bifocals Gas Perm Bitorics Gas Perm FS Toric Monovision - Soft Monovision - Disposables Monovision - Gas Perm No CL Hx Soft Daily Wear Soft Torics

Back up specs for cls?

Yes No

Primary Vision Correction:

Bifocals Contacts Contacts - Mono None Progressives Single Vision Trifocals

Interested in Laser Vision Correction?

Not Interested Yes

Last Eye Doctor:

Primary Care Physician:

Eye Hx: Infections, Injuries, Surgeries

Family Eye History: (GLC, AMD)

Eye Meds:

Systemic Meds:

Med Hx: (Diabetes,HTN,Seizures,Thyroid,Arthritis)

Family Med History:

Drug or Seasonal Allergies:

SYSTEM
DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

none General:
none dry mouth cough ear ache hard of hearing stuffy nose Ears, Nose, Throat:
none High BP racing pulse Cardiovascular:
none congestion short of breath wheezing Respiratory:
none frequent urination impotence painful urination yellow jaundice Genital, Kidney, Bladder:
none arthritis cramps joint pain stiffness swelling Muscles, Bones, Joints:
none growths pimples, warts rash Skin:
none headache numbness, paralysis seizures Neurological:
none anxiety depression insomnia Psychiatric:
none diabetes hypothyroid Endocrine:
none anemia bleeding cholestrolemia Blood/Lymph:
none hives itching lupus redness sneezing swelling Allergic/Immunologic

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