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 Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Doan, Anh	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 AETNA AMERITAS AVESIS Blue Cross Blue Shield CIGNA EYEMED GPA Human Vision Care Humana Medical MEDICARE NVA PHCS Principal SAFEGUARD Superior United Health Care 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 AETNA AMERITAS AVESIS Blue Cross Blue Shield CIGNA EYEMED GPA Human Vision Care Humana Medical MEDICARE NVA PHCS Principal SAFEGUARD Superior United Health Care 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 AETNA AMERITAS AVESIS Blue Cross Blue Shield CIGNA EYEMED GPA Human Vision Care Humana Medical MEDICARE NVA PHCS Principal SAFEGUARD Superior United Health Care 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

Family Patients:

Who can we thank for referring you:

Computer usage per day

8 hours or more 5 to 8 hours 2 to 5 hours up to 2 hours none

Sports, Hobbies, Interests

Date of last exam:

Last Eye Doctor:

Ever worn Glasses?

Yes No

When?

List any eye glass problems

Ever Worn Contact Lenses?

Yes No

When?

List any contact lens problems

Would you like to be fitted for contact lenses at this time?

Yes No

How often do you plan on wearing your contact lenses

Every day Weekends Sports purposes Special occasion

Blurry vision

Yes No

Dry eyes

Yes No

Red eyes

Yes No

Burning

Yes No

Itchy eyes

Yes No

Watery eyes

Yes No

Grittyness

Yes No

Flashes or

Yes No

Cataract

No Yes

Glaucoma

No Yes

Lazy eye

No Yes

Headaches

No Yes

Migraine

No Yes

Allergies

No Yes

Eye surgery

High blood

No Yes

Diabetes

No Yes

High cholesterol

No Yes

Thyroid

No Yes

Arthritis

No Yes

Heart attack

No Yes

Stroke

No Yes

Primary Care Physician:

Notes:

Eye drops (include over the counter):

Systemic Medications

Medication Allergies:

Cataract

Glaucoma

Macular Degeneration

Retinal Detachment

Blindness

High BP

Diabetes

Stroke

Cancer

Arthritis

Thyroid

High Cholesterol

NOTES/SOCIAL HISTORY

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