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

PATIENT MEDICAL HISTORY
Please select any problems you may have from the drop downs below.

Please list any Injuries, Surgeries, Hospitalization
Pregnant Or Nursing: Recent Tetanus Shot:
Primary Care Physcian: Last Visit: Reason For Visit:
List any Vitamins you take:
Please list any over the Counter medications:
Please list your current Prescription Medications: No Current Medications
Please list all drug allergies: No Known Drug Allergies

FAMILY MEDICAL HISTORY
Do you have a history of any of the following in your family? (Please select from the drop downs below.)


Occupation: Hobbies:
Smoking Status: Type: How Long:
Alcohol: Type: How Long:
Illegal Drugs: Type: How Long: STD:

PATIENT OCULAR HISTORY
Please list all eye problems you have had:
(Itching, Burning, Amblyopia, Eye Injuries, Surgery, Flashes of Light, Floaters, Strabismus, Catatracts, Glaucoma, Retinal Disorders, etc)

List all your current eye medications
Last Eye Doctor: Last Eye Exam:
 
FAMILY OCULAR HISTORY

Glaucoma: Crossed / Lazy: Retinal Detach: Macular Degeneration: Cataracts:

Primary Vision Correction:   Planning to get new glasses?  Back up specs?

Type of CLs worn in past:  Wear Time: Cleaner: Disposal:

Preferred Language:  Ethnicity:   Race: 
 

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
 ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux






















Submit Data / Patient Signatures



Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

View Bowersox Vision Center, PSC Practice Policies Form

Medicare and some other carriers do not pay for refraction. There will be a $30 (generally) fee for refraction if your insurance does not cover refraction. Refraction is the part of the exam where your glasses or contact lens power is determined.
Check this box if you would like to not have this part of the exam done.

Bowersox Vision Center (BVC) will contact you using the phone number you provided. Unless you indicate otherwise, your spouse may receive medical information from this office about you. You agree to receive communications concerning your visit / treatment / account / notification that materials are ready for pick-up
Check this box if you do not want to be contacted with the phone number provided.

Check this box if you do not want your medical information discussed with your spouse.

I acknowledge that I am responsible for any amounts not covered by my insurance & have been made aware of the Appointment Policy. I understand the information above and have had the opportunity to ask questions to my satisfaction.

Signature: Date:


After Completing All Forms Submit Data on Final Tab