New Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Master
Miss
Rev.
Address:
City:
State/ZipCode
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
TX
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
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Peterson OD PC, Walter
Dr. Peterson OD, Blake
Dr. General, Provider
Dr. Hudson OD, Elizabeth
Dr. GENERAL
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Master
Miss
Rev.
Address
City
State
ZipCode
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
TX
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Primary
Insurance Information
Insurance Name:
None
ACORDIA
Adventist Risk Management
AETNA
Alliant Health Plans, Inc
BC/BS
Medicare
Champva
Cigna
Family Life Insurance Co
first health/mail handlers
HealthSCOPE Benefits, Inc.
HUMANA GOLD CHOICE /KY
MEDICAID
POMCO
self-pay
Tri-Care South
UNITED HEALTH CARE
Veterans Administration
Vision Care Direct
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
ACORDIA
Adventist Risk Management
AETNA
Alliant Health Plans, Inc
BC/BS
Medicare
Champva
Cigna
Family Life Insurance Co
first health/mail handlers
HealthSCOPE Benefits, Inc.
HUMANA GOLD CHOICE /KY
MEDICAID
POMCO
self-pay
Tri-Care South
UNITED HEALTH CARE
Veterans Administration
Vision Care Direct
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
ACORDIA
Adventist Risk Management
AETNA
Alliant Health Plans, Inc
BC/BS
Medicare
Champva
Cigna
Family Life Insurance Co
first health/mail handlers
HealthSCOPE Benefits, Inc.
HUMANA GOLD CHOICE /KY
MEDICAID
POMCO
self-pay
Tri-Care South
UNITED HEALTH CARE
Veterans Administration
Vision Care Direct
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
List all medications you are currently taking (including any OTC/vitamins):
Allergies/Alerts:
Please list any Injuries, Surgeries, or Hospitalizations and the date of the occurrence
Notes:
Physician's Name:
Last Visit Date:
SOCIAL HISTORY (confidential)
How often do you consume alcohol:
Never
Occasionally
Daily
How often do you smoke/use tobacco products?
Never
Occasionally
Daily
Do you have?
HIV
Hepatitis
STDs
Hobbies:
Work:
Submit Data