New Patient Form

Please fill in all spaces. When finished, click the Submit Data button at the bottom of this form.
  • Demographics
  • Primary Medical Insurance
  • Secondary/Suppl/Vision Ins
  • Tertiary Insurance
  • Eye History
  • Submit Data

    • Demographics - Please enter your information exactly as it appears on your insurance policy.

    TitleFirstLastMISuffixNickname
    Address:
    City: State/ZipCode
    Home Phone: Work Phone:
    Other Phone:
    Cell Phone: Preferred Contact Method:
    SSN Email
    Birthday Occupation
    Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
    Marital Status Guardian or Emergency Contact
    Billing Information Is The Billing Address the Same?
    TitleFirstLastMISuffix
    Address

    CityStateZipCode
    Home Phone:
    Work Phone:

    Eye History

    If something doesn't apply, please put N/A

    PATIENT OCULAR HISTORY: Please describe any eye-related injuries, infections, diseases
    EYE MEDICATIONS CURRENTLY TAKING:
    LAST EYE EXAM:
    LAST EYE DOCTOR:
    PROCEDURE(s): Please describe any eye surgeries you have had
    SURGEON:
    PROCEDURE DATE:
    FAMILY OCULAR HISTORY: Please describe any relevant eye problems within your family
    PRIMARY VISION CORRECTION:
    Do you wear SUNWEAR?
    Do you wear COMPUTER GLASSES?
    Do you have BACK UP GLASSES?
    TYPE OF CONTACT LENSES WORN:
    BRAND OF CONTACT LENSES WORN:
    WEAR TIME:
    DISPOSAL FREQUENCY:

    Medical History

    PRIMARY CARE PHYSICIAN:
    PHONE NUMBER OF PRIMARY CARE PHYSICIAN:
    NAME OF PRACTICE OF PRIMARY CARE PHYSICIAN:
    LAST VISIT TO PRIMARY CARE PHYSICIAN
    REASON FOR LAST VISIT TO PRIMARY CARE PHYSICIAN:
    ENDOCRINOLOGIST:
    PHARMACY NAME AND ADDRESS:
    PATIENT MEDICAL HISTORY: Please describe any past or present medical issues affecting your health
    INJURIES, SURGERIES, HOSPITALIZATIONS:
    PRESCRIPTION MEDICATIONS CURRENTLY TAKING:
    DRUG ALLERGIES:
    OVER-THE-COUNTER MEDICATIONS CURRENTLY TAKING:
    VITAMINS CURRENTLY TAKING:
    FAMILY MEDICAL HISTORY: Please describe any relevant medical problems within your family
    HOBBIES:
    PREGNANT OR NURSING?
    RECENT TETANUS SHOT?
    TOBACCO USE:
    TYPE OF TOBACCO USED:
    HOW LONG HAVE YOU BEEN USING TOBACCO?
    ALCOHOL USE:
    TYPE:
    HOW LONG HAVE YOU BEEN USING ALCOHOL?
    ILLEGAL DRUG USE:
    TYPE OF DRUGS USED:
    HOW LONG HAVE YOU BEEN USING DRUGS?
    SEXUALLY TRANSMITTED DISEASES:

    PREFERRED LANGUAGE
    RACE
    ETHNICITY
    HEIGHT - Feet
    Inches
    Weight

    Primary Medical Insurance -PLEASE DO NOT USE SPACES OR DASHES (this space is for your medical insurance only, not for vision supplements; please enter that in the following section)

    Insurance Information
    Insurance Name:
    Insurance ID:
    Insurance Policy Group:
    Not Primary on Policy: Not Primary
    Primary on Policy - Skip this section if the patient is the primary member
    Name:Last, First MI
    Relationship to Insured:Spouse Child Other
    Sex: Male Female
    Address:
    City: State: Zip:
    Phone Number:
    Birthday:
    SSN:
    Employer/School:

    Secondary/Supplemental/VISION Insurance

    Insurance Information
    Insurance Name:
    Insurance ID:
    Insurance Policy Group:
    Not Primary on Policy: Not Primary
    Primary on Policy - Skip this section if the patient is the primary member
    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

    Insurance Information
    Insurance Name:
    Insurance ID:
    Insurance Policy Group:
    Not Primary on Policy: Not Primary
    Primary on Policy - Skip this section if the patient is the primary member
    Name:Last, First MI
    Relationship to Insured:Spouse Child Other
    Sex: Male Female
    Address:
    City: State: Zip:
    Phone Number:
    Birthday:
    SSN:
    Employer/School:
    After Completing All Fields, Please click the "Submit Data" button. Once submitted, you will need to request a new passcode to make additional changes.