New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical History

Please select all medical conditions:

Medications:   Allergies: 

Please list all Injuries, Surgeries, and Hospitalizations
Pregnant Or Nursing:
Recent Tetanus Shot:
Primary Care Physcian:
Last Visit:
Reason For Visit:
Please list all current medications:
Please note any family history conditions: (please select from drop downs below)
Occupation:
Hobbies:

Smoking Status: Type: How Long:

Alcohol: Type: How Long:

Illegal Drugs: Type:  How Long:   STD:

Ocular History:   Eye Meds:   Last Eye Exam:   Doctor: 

FAMILY OCULAR HISTORY
Glaucoma:   Cataracts:   Macular Degen:   Retinal Detach: 

Crossed/Lazy:   Primary Vision Correction:   Back up specs?    Planning to get new glasses? 

Other:   Type of CLs worn in past:   Wear Time:   Cleaner:   Disposal: 

Notes: 

Race:   Ethnicity:   Preferred Language: 

Submit Data

After Completing All Forms Submit Data on Final Tab