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:
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	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Bird, Jennifer Dr. Farooque, Naveera Dr. Galos, Tricia	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 ADVANTICA AETNA ALWAYS CARE Ameritas Life Ins AVESIS BLOCK VISION BLUE CROSS BLUE SHIELD OF TX CIGNA CIGNA GOVERNMENT SERVICES CIGNA INTERNATIONAL DAVIS VISION Entrust Inc. EYEMED FMH Core Source Health Smart Benefit Solutions Henner HUMANA HUMANA CHOICE CARE MEDICAID TRADITIONAL TX MEDICARE MES VISION New Insurance New Insurance NVA (NATIONAL VISION ADMINISTRATORS) OPTICARE SAFEGUARD SPECTERA/OPTUM HEALTH SVS (SUPERIOR VISION SERVICES) TRICARE UNITED HEALTHCARE VBA (VISION BENEFITS OF AMERICA) VCP (Vision Care Plan/CompBenefits) VSP (Discount Plan) VSP (Vision Service Plan) Washington National
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 ADVANTICA AETNA ALWAYS CARE AVESIS BLOCK VISION BLUE CROSS BLUE SHIELD OF TX CIGNA CIGNA GOVERNMENT SERVICES CIGNA INTERNATIONAL DAVIS VISION Entrust Inc. EYEMED FMH Core Source HUMANA HUMANA CHOICE CARE MEDICAID TRADITIONAL TX MEDICARE MES VISION New Insurance NVA (NATIONAL VISION ADMINISTRATORS) OPTICARE SAFEGUARD SPECTERA/OPTUM HEALTH SVS (SUPERIOR VISION SERVICES) TRICARE UNITED HEALTHCARE VBA (VISION BENEFITS OF AMERICA) VCP (Vision Care Plan/CompBenefits) VSP (Discount Plan) VSP (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 ADVANTICA AETNA ALWAYS CARE AVESIS BLOCK VISION BLUE CROSS BLUE SHIELD OF TX CIGNA CIGNA GOVERNMENT SERVICES CIGNA INTERNATIONAL DAVIS VISION Entrust Inc. EYEMED FMH Core Source HUMANA HUMANA CHOICE CARE MEDICAID TRADITIONAL TX MEDICARE MES VISION New Insurance NVA (NATIONAL VISION ADMINISTRATORS) OPTICARE SAFEGUARD SPECTERA/OPTUM HEALTH SVS (SUPERIOR VISION SERVICES) TRICARE UNITED HEALTHCARE VBA (VISION BENEFITS OF AMERICA) VCP (Vision Care Plan/CompBenefits) VSP (Discount Plan) VSP (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

Occupation:

None Accountant Baker Banker Cashier Computer programmer Dentist Doctor Engineer Flight Attendant Housewife Nurse Pilot Sales Self Employed Student Teacher Waiter

Employer:

Name:

Referred By:

Friend Insurance website Drive-by Internet Yellow pages Sponsored Event Advertisement

Vision Insurance:

None ADVANTICA AETNA ALWAYS CARE AVESIS BLOCK VISION BLUE CROSS BLUE SHIELD OF TX CIGNA CIGNA GOVERNMENT SERVICES CIGNA INTERNATIONAL DAVIS VISION Entrust Inc. EYEMED FMH Core Source HUMANA HUMANA CHOICE CARE MEDICAID TRADITIONAL TX MEDICARE MES VISION New Insurance NVA (NATIONAL VISION ADMINISTRATORS) OPTICARE SAFEGUARD SPECTERA/OPTUM HEALTH SVS (SUPERIOR VISION SERVICES) TRICARE UNITED HEALTHCARE VBA (VISION BENEFITS OF AMERICA) VCP (Vision Care Plan/CompBenefits) VSP (Discount Plan) VSP (Vision Service Plan)

Primary Vision Correction:

None Single Vision Glasses Progressives Contacts Contacts-Monovision Contacts-Multifocals Bifocals Trifocals

Interested In CL?

No Yes

Ever Worn CL?

No Yes

Current CL type:

No CL History Acuvue Moist 1-day Acuvue Moist 1- day for Astigmatism Acuvue Oasys Acuvue Oasys for Astigmatism Acuvue Oasys 1-day Acuvue Oasys 1-day for Astigmatism Acuvue Vita Acuvue Vita for Astigmatism Air Optix Air Optix for Astigmatism Air Optix Night & Day Air Optix Multifocal Biofinity Biofinity Toric Biofinity Multifocal Biotrue 1-day Clariti 1-day Dailies AquaComfort Plus Dailies AquaComfort Plus Toric Dailies AquaComfort Plus Multifocal Dailies Total 1 Dailies Total 1 Multifocal MyDay 1-day Proclear 1-day RGPs(hard contacts) Ultra Ultra for Astigmatism Ultra for Presbyopia Other

Primary Care Physician:

Last Eye Doctor:

None Wade, MD

Eye Meds:

None Acular Alrex Artificial Tears Artificial Tears-Refresh Artificial Tears-Soothe Betoptic-S .25% Betoptic .5% Betagan Erythromycin FML FML Forte Gentamicin Lotemax Neosporin Ocupress Optivar Pilo Gel Propine Polytrim Pred Mild Pred Forte Patanol Restasis Timoptic .25% Timoptic .5% Tobramycin Tobradex Vigamox Voltaren Xalatan Zaditor Zymar Zylet

Systemic Meds:

Family Med History:

Family Eye History:

Allergies:

Medical History:

Problems with current CL?

No Problems Dry Poor Vision Red Eyes Irritated Eyes

Problems with glare?

No Yes

Interested in Refractive Sx?

Not Interested Yes

MEDICAL PERSONAL AND FAMILY HISTORY:

DOB:

Medical Insurance:

Aetna-HMO Aetna-PPO Aetna-POS BCBS-HMO BCBS-PPO BCBS-POS Cigna-HMO Cigna-PPO Cigna-POS Great West PHCS United Healthcare

_______________________________________________________________________________________

No Yes Sometimes

Hobbies

Sports Biking Fishing Hunting Reading Running Carpentry Automotive Metalworking Crafting Other

Spouse/Parent Name:

Race

White Black or African American Hispanic or Latino Asian Pacific Islander American Indian and Alska Native

Gender

Male Female

EyeTrauma:

No Yes

Eye Surgery:

No Yes

Vision Loss:

No Yes

Eye Hx:

No Yes

Floaters:

No Yes

Last Eye Exam:

1 year 6 months 2 years 3 years Not sure

Itch:

No Yes

Water:

No Yes

Burn:

No Yes

Cataracts:

No Yes Had surgery to remove

Glaucoma:

No Yes

Hypertension:

No Yes-Controlled Yes-Uncontrolled

Last Physical Exam:

1 year not sure

Diabetes:

Heart Dz:

No Mitral Valve Prolapse Congestive Heart Failure Heart Attack Stroke Bypass Surgery Endocarditis

Medications:

No Hypo Hyper Hashimoto's Dz Grave's Dz

Lung Dz:

No Asthma Emphysema

Arthritis:

No Age Related Injury Related Rheumatoid Juvenile Rheumatoid

Auto Immune:

No Lupus

Skin:

No Dermatitis Psoriasis Vitiligo

Urogenital:

No Kidney Dz Kidney Stones Prostate Cancer Urinary Tract Infection

Neuro:

No Epilepsy Brain Tumor

Gastric:

No Reflux IBS Ulcers Fundoplication Stomach Reduction Sx

Psych:

No Depression Anxiety Bipolar Disorder Manic Depression Schizophrenia

Cancer:

No Lung Cancer Breast Cancer Colon Cancer

Gen Health:

Normal Has a Cold Has the Flu Headache Fever Malaise Sore Throat

Blood:

No Anemia Leukemia Hemophelia

Pregnant

Yes

Diplopia:

No Yes

Other:

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