New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
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
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary Vision

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:

Second Vision

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:

Primary Medical

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:

Second Medical

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:

Third Medical

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

To save time during your exam, please fill out as much information as possible. Thank you.


CHIEF CONCERN
No vision correctionWears glasses Wears contact lenses
How did you hear about our office?

PAST OCULAR HISTORY
GlaucomaMacula/Retinal DiseaseCataracts
KeratoconusOther ocular disease
Previous ocular surgeries, injuries, or infections

PAST MEDICAL HISTORY
DiabetesHigh blood pressureCardiovascular diseaseRespiratory DiseaseHigh CholesterolThyroid Disease
Other disease

CURRENT MEDICATIONS No current Meds
Vitamins
Over the counter drugs

Allergies NKDA


Family Medical History (Please list condition and who)
Family Ocular History (Please list condition and who)

Name of Family Physician Date of Last Exam
Name of Last Eye Doctor Date of Last Eye Exam

Other information

CONTACT LENSES
Interested in a contact lens exam?Currently wear contact lenses?Soft ContactsRigid Gas Perm Lenses

Brand Name Right Eye Base Curve Power
Brand Name Left Eye Base Curve Power
# Hours worn each day
How often do you throw away the contacts?
How often are you supposed to throw them away?
Do you sleep in your contacts?


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


These questions are solely asked to meet the Government Meaningful Use criteria for electronic medical records and will be used for no other purpose.

Height Feet: Inches: Weight: Preferred Language : Race: Ethnicity:


OFFICE POLICIES
By checking this box, I allow Premier Eyecare of Arizona to file medical or vision insurance claims on my behalf.
By checking this box, I acknowledge that I will be financially responsible for any balance not paid by my insurance. I also acknowledge that custom eyewear is nonrefundable.
By checking this box, I acknowledge that I have read a copy of the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have read a copy of the Notice of Privacy Practices and Patient Consent Form. Checking this box allows Premier Eyecare of Arizona to conduct normal office procedures in accordance with HIPAA.

I have read a copy of the Notice of Privacy Practices and Patient Consent Form.
This allows Premier Eyecare of Arizona to conduct normal office procedures in accordance with HIPAA and file insurance claims on my behalf.
I acknowledge that I will be financially responsible for any balance not paid by my insurance.

SIGNATURE / TYPE YOUR NAME Date

Submit Data

Please click the "SUBMIT DATA" button and your information will be electronically sent to our office. Thank you.