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
After Completing All Forms Submit Data on Final Tab