New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
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:

Primary

Insurance Information
Insurance Name:
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:
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:
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

Briefly describe the main reason for having an examination today:
Associated: Do you have any other symptoms related to this?
Other eye issues or problems:
Currently wear glasses Full-time Part-time
If part-time, how often/when?
Currently wear contacts Full-time Part-time
If part-time, how often/when?
Soft Rigid Gas Permeable
Are your lenses comfortable?YesNo
Current Brand:
What solution do you use?
What is your replacement schedule?
How old is your current pair?
Please list all eyedrops you use (over-the-counter and prescription):
How often used?:
Are you currently experiencing or do you have a history of any of the following?
Blindness Eye Turn Lazy Eye Keratoconus Macular Degeneration Retinal Detachment Glaucoma Cataracts Headaches Blurred Vision Double Vision Eyes Hurt or Tired Floaters Flashing Lights Eyes Feel Sandy/Gritty Halos Around Lights Light or Sun Sensitivity Styes Redness Itching Burning Tearing Dryness
Other eye disease or condition:
Describe any eye injuries:
List any eye surgeries:
How many hours a day do you use a computer?
Describe any visual symptoms from computer use:
When did you last see your physician?
List all medications you are currently taking (including any over-the-counter and vitamins/supplements):
Please list any medication allergies:
Are you pregnant? Yes No
If yes, what is the due date?
Are you having or have you ever had chronic problems with any of the following?
Migraines Multiple Sclerosis Diabetes Thyroid Problems Arthritis Allergies/Hay Fever Asthma Emphysema High Blood Pressure Stroke Anemia Cancer
Notes:
Weight
Physician's Name:

Submit Data

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