New Patient Form

Please fill out as much information as possible on each tab.
After completing all forms Submit Data on final tab. Thank you!

Demographics



ALL AREAS THAT MUST BE FILLED OUT, WILL BE MARKED WITH A RED *

Title*First*LastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
*Cell Phone: Preferred Contact Method:
*Email
*Birthday Occupation
*Sex Male Female Employment Status Employed Student Retired
Marital Status Employer/School Name
Misc/Guardian

Billing Information
Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Ocular History

Please select the reason for your visit today:
Any other difficulties/complaints:

Please list history of any of the following:
Cataracts, Lazy/Crossed eye, Retinal Detachment, Glaucoma, Injuries, Surgeries, Other
Last Eye Exam:
Previous Eye Doctor:
Current Vision Correction:
Age of Current Glasses/Contacts:
Family History of Cataracts?
Family History of Crossed/Lazy Eye?
Family History of Glaucoma?
Family History of Macular Degeneration?
Family History of Retinal Detachment?
NOTES:

Medical History

Please list if you have a history of any of the following:
Cancer, Diabetes, Heart Disease, High Blood Pressure, High Cholesterol, Thyroid Problems, Other
List Major Injuries, Surgeries, Hospitalization
Pregnant Or Nursing?
Primary Care Physician:
Last Visit:
Please select prescription medications:
Medication 2
Medication 3
List any other medications:
Eye Medications:
Glaucoma Medications:
OTC/Vitamins:
Drug Allergies:

Please select any FAMILY history of the following:
Cancer, Diabetes, Heart Disease, High Blood Pressure, High Cholesterol, Thyroid Problems, Other
Family Medical History 2
Family Medical History 3
Please list any other Family Medical Conditions:
Occupation:
Hobbies:

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