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. LLERENA-LAW, CRISTINA Dr. REINSTEIN, FRAN Dr. SCHULMAN, ERICA Dr. THAU, ANDREA Dr. VRICELLA, MARILYN	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:

Primary

Insurance Information

Insurance Name:	None 1199 SEIU NATIONAL BENEFIT FUND 21ST 21ST 21ST 21ST 21ST 21ST 21ST CENTURY HEALTH & BENEFITS, INC 21ST CENTURY HEALTH AND BENEFITS, INC. AARP HEALTHCARE OPTIONS ACEC/ HEALTH PLAN SERVICES, INC ACS/HEALTHNET ADMINISTRATIVE CONCEPTS, INC. ADVENTIST RISK MANAGEMENT AETNA AETNA AETNA/PPO AETNA/USHEALTHCARE AETNA/USHEALTHCARE AFTRA HEALTH FUND ALLIED BENEFIT SYSTEMS, INC. AMA INSURANCE AGENCY, INC AMALGAMATED LIFE AMERICAN BENEFIT ADMINISTRATIVE SERVICES AMERICAN CHOICE HEALTH CARE PLAN ANTHEM HEALTH OF NY ATLANTIS HEALTH PLAN AUSA LIFE INSURANCE COMPANY, INC AZIMUTH RISK SOLUTIONS BANKERS LIFE AND CASUALTY COMPANY BENEFIT PLAN MANAGEMENT BENEFIT SYETEMS & SERVICES, INC BENESIGHT CAPITAL DISTRICT PHYSICIANS CAREFIRST ADMINISTRATORS CDPHN CELTIC SPECIAL HEALTH CHESTERFIELD RESOURCES, INC. CHICKERING CLAIMS ADM, INC. CIGNA HEALTHCARE CIGNA INTERNATIONAL CLAIM MANAGEMENT SERVICES CONSOLIDATED HEALTH PLANS CONTINENTAL GENERAL INSURANCE CO. CORESOURCE, INC CORPORATE BENEFIT SERVICES OF AMERICA, I CROSSAMERICA HEALTH PLANS DC 1707 HEALTH & INS. FUND DGA-PROD. HEALTHPLANS DIRECTORS GUILD OF AMERICA DIVERSIFIELD ADMINISTRATION CORP. EASTERN BENEFIT SYSTEMS CHOICE PLAN B. EMBLEM HEALTH EMPIRE BLUE CROSS/SHIELD EMPIRE BLUE CROSS/SHIELD, BLUE CARD PROG EMPLOYEE BENEFIT MANAGEMENT SERVICES FISERV HEALTH FORTIS INSURANCE COMPANY GALLAGHER BENEFIT ADMINISTRATIORS, INC. GE GROUP ADMINISTRATORS GE HEALTH MANAGER GEHA GENERAL AMERICAN GENWORTH LIFE AND ANNUITY INS. CO GILFORD SECURITIES, INC. GLHIC MEDICAL CLAIMS GLOBAL MEDICAL MANAGEMENT GOLDEN RULE INSURANCE COMPANY GREAT-WEST LIFE & ANNUITY INS CO. GREAT WEST GROUP & PENSION ADMINISTRATORS, INC. GROUP ADMINISTRATORS, LTD GROUP HEALTH INCORPORATED (GHI) GUARDIAN GUILD TIMES BENEFITS FUND HARRINGTON BENEFIT SERVICES HARVARD PILGRIM HCCMIS CLAIMS DEPARTMENT HCI HEALTH ADMINISTRATORS, INC HEALTH NEW ENGLAND HEALTH PLANS, INC HEALTHNET FEDERAL SERVICES, INC HEALTHNOW NY, INC HEALTHPLUS AMERIGROUP HIP HORIZON BLUE CROSS/BLUE SHIELD OF NJ HORIZON HEALTHCARE OF NY HPHC IDA IEES INTERNATIONAL BENEFITSS ADMINISTRATORS J.F MOLLOY & ASSOCIATES, INC. JOHN ALDEN LIFE INSURANCE CO. KLAIS & COMPANY, INC. LOCAL 107 - LABOR-MANAGEMENT TRUST FUND LOCAL 840 HEALTH INS. FUND LUMENOS MAGNAPREFERRED DIRECT PLUS/LOCAL 840 MAMSI LIFE AND HEALTH INS CO. MEDICA MEDICAL MUTUAL MEDICARE MEDIPLAN, INC MERITAIN MERITAIN HEALTH METROPLUS HEALTH PLAN MMSI MUTUAL ASSURANCE ADMINISTRATORS MUTUAL OF AMERICA ATTN: EMPLOYEE BNFTS MVP NCAS NEW ENGLAND FINANCIAL New Insurance NGS AMERICAN NIPPON LIFE INSURANCE CO. ONE HEALTH PLAN OXFORD HEALTH PLANS P5 ELECTRONIC HEALTH SERVICES PARAMOUNT PERFECTHEALTH PERFORMAX PERFORMAX PERFORMAX PHCS PHL GROUP MEDICAL CLAIMS PHOENIX GROUP SERVICES POMCO PREFERRED ADMINISTRATIVE SERVICES PRINCIPAL LIFE INSURANCE CO. PRUDENTIAL HEALTH SAINT BARNABAS SYSTEM HEALTH PLAN SCREEN ACTORS GUILD PRODUCER HEALTH PLAN SEABURY & SMITH, INC SELFPAY PATIENTS STARMARK STUDENT INSURANCE STUDENT RESOURCES SUTTON SPECIAL RISK THE CAPELLA GROUP THE LOOMIS COMPANY THE UNION LABOR LIFE INSURANE COMPANY TILE LAYERS LOCAL 52 INS & WELFARE FUND TR PAUL INC. TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY TRAVELERS UMR UNICARE UNITED AMERICAN INSURANCE COMPANY UNITED HEALTHCARE UNITED SECURITY LIFE INS CO. UNITEDHEALTHCARE STUDENT RESOURCES UPMC USI USI ADMINISTRATORS WAUSAU BENEFITS WINE, LIQUOR & DISTILLERY WORKERS UNION WRITERS GUILD-INDUSTRY HEALTH FUND
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 1199 SEIU NATIONAL BENEFIT FUND 21ST 21ST 21ST 21ST 21ST 21ST 21ST CENTURY HEALTH & BENEFITS, INC 21ST CENTURY HEALTH AND BENEFITS, INC. AARP HEALTHCARE OPTIONS ACEC/ HEALTH PLAN SERVICES, INC ACS/HEALTHNET ADMINISTRATIVE CONCEPTS, INC. ADVENTIST RISK MANAGEMENT AETNA AETNA AETNA/PPO AETNA/USHEALTHCARE AETNA/USHEALTHCARE AFTRA HEALTH FUND ALLIED BENEFIT SYSTEMS, INC. AMA INSURANCE AGENCY, INC AMALGAMATED LIFE AMERICAN BENEFIT ADMINISTRATIVE SERVICES AMERICAN CHOICE HEALTH CARE PLAN ANTHEM HEALTH OF NY ATLANTIS HEALTH PLAN AUSA LIFE INSURANCE COMPANY, INC AZIMUTH RISK SOLUTIONS BANKERS LIFE AND CASUALTY COMPANY BENEFIT PLAN MANAGEMENT BENEFIT SYETEMS & SERVICES, INC BENESIGHT CAPITAL DISTRICT PHYSICIANS CAREFIRST ADMINISTRATORS CDPHN CELTIC SPECIAL HEALTH CHESTERFIELD RESOURCES, INC. CHICKERING CLAIMS ADM, INC. CIGNA HEALTHCARE CIGNA INTERNATIONAL CLAIM MANAGEMENT SERVICES CONSOLIDATED HEALTH PLANS CONTINENTAL GENERAL INSURANCE CO. CORESOURCE, INC CORPORATE BENEFIT SERVICES OF AMERICA, I CROSSAMERICA HEALTH PLANS DC 1707 HEALTH & INS. FUND DGA-PROD. HEALTHPLANS DIRECTORS GUILD OF AMERICA DIVERSIFIELD ADMINISTRATION CORP. EASTERN BENEFIT SYSTEMS CHOICE PLAN B. EMBLEM HEALTH EMPIRE BLUE CROSS/SHIELD EMPIRE BLUE CROSS/SHIELD, BLUE CARD PROG EMPLOYEE BENEFIT MANAGEMENT SERVICES FISERV HEALTH FORTIS INSURANCE COMPANY GALLAGHER BENEFIT ADMINISTRATIORS, INC. GE GROUP ADMINISTRATORS GE HEALTH MANAGER GEHA GENERAL AMERICAN GENWORTH LIFE AND ANNUITY INS. CO GILFORD SECURITIES, INC. GLHIC MEDICAL CLAIMS GLOBAL MEDICAL MANAGEMENT GOLDEN RULE INSURANCE COMPANY GREAT-WEST LIFE & ANNUITY INS CO. GREAT WEST GROUP & PENSION ADMINISTRATORS, INC. GROUP ADMINISTRATORS, LTD GROUP HEALTH INCORPORATED (GHI) GUARDIAN GUILD TIMES BENEFITS FUND HARRINGTON BENEFIT SERVICES HARVARD PILGRIM HCCMIS CLAIMS DEPARTMENT HCI HEALTH ADMINISTRATORS, INC HEALTH NEW ENGLAND HEALTH PLANS, INC HEALTHNET FEDERAL SERVICES, INC HEALTHNOW NY, INC HEALTHPLUS AMERIGROUP HIP HORIZON BLUE CROSS/BLUE SHIELD OF NJ HORIZON HEALTHCARE OF NY HPHC IDA IEES INTERNATIONAL BENEFITSS ADMINISTRATORS J.F MOLLOY & ASSOCIATES, INC. JOHN ALDEN LIFE INSURANCE CO. KLAIS & COMPANY, INC. LOCAL 107 - LABOR-MANAGEMENT TRUST FUND LOCAL 840 HEALTH INS. FUND LUMENOS MAGNAPREFERRED DIRECT PLUS/LOCAL 840 MAMSI LIFE AND HEALTH INS CO. MEDICA MEDICAL MUTUAL MEDICARE MEDIPLAN, INC MERITAIN MERITAIN HEALTH METROPLUS HEALTH PLAN MMSI MUTUAL ASSURANCE ADMINISTRATORS MUTUAL OF AMERICA ATTN: EMPLOYEE BNFTS MVP NCAS NEW ENGLAND FINANCIAL New Insurance NGS AMERICAN NIPPON LIFE INSURANCE CO. ONE HEALTH PLAN OXFORD HEALTH PLANS P5 ELECTRONIC HEALTH SERVICES PARAMOUNT PERFECTHEALTH PERFORMAX PERFORMAX PERFORMAX PHCS PHL GROUP MEDICAL CLAIMS PHOENIX GROUP SERVICES POMCO PREFERRED ADMINISTRATIVE SERVICES PRINCIPAL LIFE INSURANCE CO. PRUDENTIAL HEALTH SAINT BARNABAS SYSTEM HEALTH PLAN SCREEN ACTORS GUILD PRODUCER HEALTH PLAN SEABURY & SMITH, INC SELFPAY PATIENTS STARMARK STUDENT INSURANCE STUDENT RESOURCES SUTTON SPECIAL RISK THE CAPELLA GROUP THE LOOMIS COMPANY THE UNION LABOR LIFE INSURANE COMPANY TILE LAYERS LOCAL 52 INS & WELFARE FUND TR PAUL INC. TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY TRAVELERS UMR UNICARE UNITED AMERICAN INSURANCE COMPANY UNITED HEALTHCARE UNITED SECURITY LIFE INS CO. UNITEDHEALTHCARE STUDENT RESOURCES UPMC USI USI ADMINISTRATORS WAUSAU BENEFITS WINE, LIQUOR & DISTILLERY WORKERS UNION WRITERS GUILD-INDUSTRY HEALTH FUND
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 1199 SEIU NATIONAL BENEFIT FUND 21ST 21ST 21ST 21ST 21ST 21ST 21ST CENTURY HEALTH & BENEFITS, INC 21ST CENTURY HEALTH AND BENEFITS, INC. AARP HEALTHCARE OPTIONS ACEC/ HEALTH PLAN SERVICES, INC ACS/HEALTHNET ADMINISTRATIVE CONCEPTS, INC. ADVENTIST RISK MANAGEMENT AETNA AETNA AETNA/PPO AETNA/USHEALTHCARE AETNA/USHEALTHCARE AFTRA HEALTH FUND ALLIED BENEFIT SYSTEMS, INC. AMA INSURANCE AGENCY, INC AMALGAMATED LIFE AMERICAN BENEFIT ADMINISTRATIVE SERVICES AMERICAN CHOICE HEALTH CARE PLAN ANTHEM HEALTH OF NY ATLANTIS HEALTH PLAN AUSA LIFE INSURANCE COMPANY, INC AZIMUTH RISK SOLUTIONS BANKERS LIFE AND CASUALTY COMPANY BENEFIT PLAN MANAGEMENT BENEFIT SYETEMS & SERVICES, INC BENESIGHT CAPITAL DISTRICT PHYSICIANS CAREFIRST ADMINISTRATORS CDPHN CELTIC SPECIAL HEALTH CHESTERFIELD RESOURCES, INC. CHICKERING CLAIMS ADM, INC. CIGNA HEALTHCARE CIGNA INTERNATIONAL CLAIM MANAGEMENT SERVICES CONSOLIDATED HEALTH PLANS CONTINENTAL GENERAL INSURANCE CO. CORESOURCE, INC CORPORATE BENEFIT SERVICES OF AMERICA, I CROSSAMERICA HEALTH PLANS DC 1707 HEALTH & INS. FUND DGA-PROD. HEALTHPLANS DIRECTORS GUILD OF AMERICA DIVERSIFIELD ADMINISTRATION CORP. EASTERN BENEFIT SYSTEMS CHOICE PLAN B. EMBLEM HEALTH EMPIRE BLUE CROSS/SHIELD EMPIRE BLUE CROSS/SHIELD, BLUE CARD PROG EMPLOYEE BENEFIT MANAGEMENT SERVICES FISERV HEALTH FORTIS INSURANCE COMPANY GALLAGHER BENEFIT ADMINISTRATIORS, INC. GE GROUP ADMINISTRATORS GE HEALTH MANAGER GEHA GENERAL AMERICAN GENWORTH LIFE AND ANNUITY INS. CO GILFORD SECURITIES, INC. GLHIC MEDICAL CLAIMS GLOBAL MEDICAL MANAGEMENT GOLDEN RULE INSURANCE COMPANY GREAT-WEST LIFE & ANNUITY INS CO. GREAT WEST GROUP & PENSION ADMINISTRATORS, INC. GROUP ADMINISTRATORS, LTD GROUP HEALTH INCORPORATED (GHI) GUARDIAN GUILD TIMES BENEFITS FUND HARRINGTON BENEFIT SERVICES HARVARD PILGRIM HCCMIS CLAIMS DEPARTMENT HCI HEALTH ADMINISTRATORS, INC HEALTH NEW ENGLAND HEALTH PLANS, INC HEALTHNET FEDERAL SERVICES, INC HEALTHNOW NY, INC HEALTHPLUS AMERIGROUP HIP HORIZON BLUE CROSS/BLUE SHIELD OF NJ HORIZON HEALTHCARE OF NY HPHC IDA IEES INTERNATIONAL BENEFITSS ADMINISTRATORS J.F MOLLOY & ASSOCIATES, INC. JOHN ALDEN LIFE INSURANCE CO. KLAIS & COMPANY, INC. LOCAL 107 - LABOR-MANAGEMENT TRUST FUND LOCAL 840 HEALTH INS. FUND LUMENOS MAGNAPREFERRED DIRECT PLUS/LOCAL 840 MAMSI LIFE AND HEALTH INS CO. MEDICA MEDICAL MUTUAL MEDICARE MEDIPLAN, INC MERITAIN MERITAIN HEALTH METROPLUS HEALTH PLAN MMSI MUTUAL ASSURANCE ADMINISTRATORS MUTUAL OF AMERICA ATTN: EMPLOYEE BNFTS MVP NCAS NEW ENGLAND FINANCIAL New Insurance NGS AMERICAN NIPPON LIFE INSURANCE CO. ONE HEALTH PLAN OXFORD HEALTH PLANS P5 ELECTRONIC HEALTH SERVICES PARAMOUNT PERFECTHEALTH PERFORMAX PERFORMAX PERFORMAX PHCS PHL GROUP MEDICAL CLAIMS PHOENIX GROUP SERVICES POMCO PREFERRED ADMINISTRATIVE SERVICES PRINCIPAL LIFE INSURANCE CO. PRUDENTIAL HEALTH SAINT BARNABAS SYSTEM HEALTH PLAN SCREEN ACTORS GUILD PRODUCER HEALTH PLAN SEABURY & SMITH, INC SELFPAY PATIENTS STARMARK STUDENT INSURANCE STUDENT RESOURCES SUTTON SPECIAL RISK THE CAPELLA GROUP THE LOOMIS COMPANY THE UNION LABOR LIFE INSURANE COMPANY TILE LAYERS LOCAL 52 INS & WELFARE FUND TR PAUL INC. TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY TRAVELERS UMR UNICARE UNITED AMERICAN INSURANCE COMPANY UNITED HEALTHCARE UNITED SECURITY LIFE INS CO. UNITEDHEALTHCARE STUDENT RESOURCES UPMC USI USI ADMINISTRATORS WAUSAU BENEFITS WINE, LIQUOR & DISTILLERY WORKERS UNION WRITERS GUILD-INDUSTRY HEALTH FUND
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

LEE:

1 year 2 years 3 years 5 years 6 months

With Dr.

AT FR MV CL ES AAT

Referred By:

CHIEF COMPLAINT

Secondary Complaints

Notes

Occupation:

Student in Advertising Artist Doctor Editor Executive assistant Lawyer Professor Retired FDNY NYPD DSNY Plumber Construction

Hobbies:

GLCCataractSurgeryTraumaDry eyeDVANVAHAEye PainDiplopia

Ocular Hx

IDDM NIDDMHTNCholesterolTHYPregnant Or Nursing:

General Health

DM FamGLC FamBlindness Fam

Family Medical History

FAMILY OCULAR HISTORY

Glasses/CLs?

None Glasses CL

How Old?

Back up specs?

No Yes

How Long Today?

Maximum Wear Time:

8 - 10 Hours 10-12 hours 12-14 Hours greater than 14 hours All day Occ. Overnight Extended

Replacement:

2 weeks monthly daily weekly yearly

Solution:

Optifree Clear Care Boston Revitalens Biotrue

No MedsNKDA

Patient attended by:

Mother Father Both parents Grandmother Grandfather

Flashes/FloatersBIRTMacula degenerationCataractsHTN High CholesterolCancer

Exam Type

CL F/U CLE Comp. Eye Exam DFE Emergency Follow Up GLC Checkup IOP check post-op cataract Pre-op LASIK

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