New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. Miss

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	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Phillips, Leilani Dr. Borstad, Brett	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

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:

Vision Insurance

Insurance Information

Insurance Name:	None AARP/ Medicare Complete Aetna Aetna 06156 Aetna 1106 Aetna 1107 Aetna 1109 Aetna 14079 Aetna 60054 Avesis Blue Cross Blue Shield Cigna Health Care Cigna Health Care 37422-7223 Cigna Health Care 5200 Cigna Health Care 7561 CNIC Health Solutions Cofinity CompBenefits Compbenefits Vision Care CoreSource Davis Vision EyeMed GEHA HealthPartners Humana Kaiser Loyal American M E S Mail Handlers Benefit Plan Medicare Medicare Part A Medicare Part B Met Life Optum Health Private Pay Rocky Mountain Health Plan RR Medicare/ Palmetto GBA Superior TRI-CARE WPS TRICARE UMB UMR United Health Care United Health Care 30555 United Health care 87726 Qwest United Health Care Intergrated Services United Healthcare 740800 Vision Service Plan (VSP) Zenith/UFCW
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

Insurance Information

Insurance Name:	None AARP/ Medicare Complete Aetna Aetna 06156 Aetna 1106 Aetna 1107 Aetna 1109 Aetna 14079 Aetna 60054 Avesis Blue Cross Blue Shield Cigna Health Care Cigna Health Care 37422-7223 Cigna Health Care 5200 Cigna Health Care 7561 CNIC Health Solutions Cofinity CompBenefits Compbenefits Vision Care CoreSource Davis Vision EyeMed GEHA HealthPartners Humana Kaiser Loyal American M E S Mail Handlers Benefit Plan Medicare Medicare Part A Medicare Part B Met Life Optum Health Private Pay Rocky Mountain Health Plan RR Medicare/ Palmetto GBA Superior TRI-CARE WPS TRICARE UMB UMR United Health Care United Health Care 30555 United Health care 87726 Qwest United Health Care Intergrated Services United Healthcare 740800 Vision Service Plan (VSP) Zenith/UFCW
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

Insurance Information

Insurance Name:	None AARP/ Medicare Complete Aetna Aetna 06156 Aetna 1106 Aetna 1107 Aetna 1109 Aetna 14079 Aetna 60054 Avesis Blue Cross Blue Shield Cigna Health Care Cigna Health Care 37422-7223 Cigna Health Care 5200 Cigna Health Care 7561 CNIC Health Solutions Cofinity CompBenefits Compbenefits Vision Care CoreSource Davis Vision EyeMed GEHA HealthPartners Humana Kaiser Loyal American M E S Mail Handlers Benefit Plan Medicare Medicare Part A Medicare Part B Met Life Optum Health Private Pay Rocky Mountain Health Plan RR Medicare/ Palmetto GBA Superior TRI-CARE WPS TRICARE UMB UMR United Health Care United Health Care 30555 United Health care 87726 Qwest United Health Care Intergrated Services United Healthcare 740800 Vision Service Plan (VSP) Zenith/UFCW
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

Breifly describe the main reason for having an examination today:

Other eye issues or problems

I currently wear glasses Full-time Part-time

If part-time, how often/when?

Occasionally Driving Reading / Computer After contact lens removal 1-2 times per week Half time Sports Weekends Social activities

I currently wear contacts Full-time Part-time

If part-time, how often/when?

Occasionally Driving 1-2 times per week Half time Sports Weekends Social activities

What type of contacts do you wear? Soft Rigid Gas Permeable
Are your contact lenses comfortable? Yes No

Current Brand:

Acuvue 1-day Acuvue 1-day Moist Acuvue 1-day Trueye Acuvue 2 Acuvue Oasys Acuvue Oasys for Astigmatism Acuvue Oasys for Presbyopia Acuvue Advance Acuvue Advance for Astigmatism Air Optix Air Optix Night & Day Air Optix Astigmatism Air Optix Multifocal Avaira Biomedic Toric Biomedic XC Biofinity Biofinity Toric Biofinity Multifocal Clearsight 1 day Clearsight 1 day Toric Focus Dailies Standard Focus Dailies AC plus Focus Dailies Toric Frequency 55 Frequency 55 Toric Frequency 55 Aspheric Freshlook colorblends Proclear Proclear 1 day Proclear EP Proclear Multifocal Purevision Purevision 2 Purevision 2 Toric Purevision Multifocal Soflens 38 Soflens Toric Soflens Daily Disposable Soflens Multifocal Vertex Toric Boston EO Boston ES Boston XO Fluoroperm 60 Menicon Z Thin RGP - unknown material

What solution do you use?

None Optifree Replenish Optifree Pure Moist Optifree Express Renu Biotrue Clear Care Kirkland Signature Revitalens Generic store brand Boston Advance Boston original Optimum B & L Gas Perm Unique Ph

What is your replacement schedule?

Daily Weekly Every 2 weeks Monthly If they feel bad Quarterly Yearly

How old is your current pair?

new 1-2 weeks 2-4 weeks very old

Please list all eyedrops you use (OTC and Rx):

How often do you use the drops?:

daily occasionally rarely

Do you have a history of any of the following? SET ALL TO NO	YES	NO
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Keratoconus
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Headaches
Blurred Vision
Double Vision
Eyes "hurt" or "tired"
Halos around lights
Bothered by light/sun
Frequent styes
Eyes frequently red
Eyes itch
Eyes burn
Eyes tear
Eyes feel dry
Eyes feel sandy/gritty
Flashing lights
Floaters

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

          

Other eye disease or condition:

Describe any eye injuries:

List any eye surgeries:

How many hours a day do you use a computer?

<2 hours 2 - 4 hours 5 - 8 hours 9 - 12 hours 12+ hours

Describe any visual symptoms from computer use:

Medical History

Primary Care Physician's Name:

Last Visit Date:

List all medications you are currently taking (including any OTC/vitamins):

List any medications you are allergic to:

Are you pregnant or nursing? Yes No

If yes, what is the due/birth date?

Do you have, or ever had, any CHRONIC problems in the following areas? SET ALL TO NO	YES	NO
Migraines
Multiple Sclerosis
Diabetes
Thyroid problems
Arthritis
Allergies/Hay fever
Asthma
Emphysema
High blood pressure
Stroke
Anemia
Cancer

          

 

Are you interested in contact lenses?

Yes No

Are you interested in purchasing glasses today?

Yes No

Are you interested in Lasik?

Yes No

How often do you smoke/use tobacco products? Never Occasionally Daily

How often do you consume alcohol:

Never Occasionally Daily

Do you have? Hepatitis HIVSTDs

Family history is unknown/adopted Do you have a history of any of the following in your family? (Grandparents, Parents, Siblings) SET ALL TO NO YES NO Poor vision Blindness Eye turn (Strabismus) Lazy Eye (Amblyopia) Glaucoma Cataract Macular Degeneration Retinal Detachment/Disease Cancer Diabetes High Blood Pressure Stroke Thyroid Disease Other inherited disease If yes, what disease? Who referred you to our office? If not referred, how did you hear about Belleview Eye Associates? Family member Insurance list Coworker Friend Primary Care Doctor Internet Drove by Submit Data After Completing All Forms Submit Data on Final Tab