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
Guardian name & phone #
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Plan

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:

Primary Medical

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:

Secondary Medical

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:

Visual History


I currently wear glasses:
If part-time, how often/when?
I currently wear contacts:
If part-time, how often/when?
Are your contact lenses comfortable?
Contact Lens Type
Current Contact Lens brand, Right Eye:
Current Contact Lens Brand, Left Eye:
What solution do you use?
What is your replacement schedule?
How old is your current pair?
Average Wear Time:
Days/Wk?
Wear Schedule:
Please list all eyedrops you use (OTC and Rx):


Do you have a history of any of the following vision conditions?

Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Keratoconus
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Other eye disease or condition
Headaches


Are you currently experiencing any of the following vision-related symptoms?

Blurred Vision
Double Vision
Eyes "hurt" or "tired"
Halos around lights
Bothered by light / sun light
Frequent styes
Eyes itch
Eyes burn
Eyes tear
Eyes feel dry
Eyes feel sandy/gritty
Flashing lights
Floaters
Describe any eye injuries:
List any eye surgeries:
How many hours a day do you electronic devices?
Describe any visual symptoms from electronic devise use:


Medical History


Physician's Name:
List all medications you are currently taking (including any OTC/vitamins):
Last Visit Date:
List any medications you are allergic to:


Do you have any of the following chronic conditions?

Migraines
Multiple Sclerosis
Thyroid
Diabetes Type HbAIC Diabetes last tested
Arthritis
Allergies/Hay fever
Asthma
Emphysema
High blood pressure
High Cholesterol
Stroke
Anemia
Cancer


Family History


Poor Vision / Legally Blind?
Blindness
Eye turn (Strabismus)
Lazy Eye (Amblyopia)
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment/Disease
Cancer
Diabetes
High Blood Pressure
Stroke
Thyroid Disease
Heart Disease
Any other disease(s)?


Social History

How often do you smoke/use tobacco products?
How often do you consume alcohol:


Submit Data

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