New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev.

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	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Benham, Kevin	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

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:

Medical Insurance

Insurance Information

Insurance Name:	None Advantica Aetna Allegience Benefit Plan Always Care Ameritas Avesis Block Vision Blue Cross Blue Shield Care Improvement Plus Cigna Eyemed Eyetopia Guardian Humana Humana VCP Medicare Other; See Notes PHC Primary Physicians Care Safeguard Scott & White Health Plan Payer ID 88030 Seton Health Plan Spectera Superior Vision Tricare for Life TriCare South Region United Health Care Veterans Affairs VSP VSP Supplemental Claims
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:

Vision Insurance

Insurance Information

Insurance Name:	None Advantica Aetna Allegience Benefit Plan Always Care Ameritas Avesis Block Vision Blue Cross Blue Shield Care Improvement Plus Cigna Eyemed Eyetopia Guardian Humana Humana VCP Medicare Other; See Notes PHC Primary Physicians Care Safeguard Scott & White Health Plan Payer ID 88030 Seton Health Plan Spectera Superior Vision Tricare for Life TriCare South Region United Health Care Veterans Affairs VSP VSP Supplemental Claims
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

What brings you in to see us today?
If you wear contacts, which brand do you currently wear?
How did you hear about us?

Personal Eye History: Please list any previous illness/disease/surgeries associated with your eyes.

Personal Health History: Please list medical conditions that apply to you.

Family Eye History: Please list any eye illness/disease that apply to family members.

Family Health History: Please list medical conditions that apply to family members.

Do you use tobacco? If yes, type/amount/how long?

Do you drink alcohol? If yes, type/amount/how long?

Any hobbies or special visual needs?
Yes
Is there any possibility of pregnancy?

Please list any drug allergies:

Your current medications:

Submit Data