New Patient Form

Demographics

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

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. Slaugh OD, Russell Dr. Hayashida OD, Ron Dr. Lowman OD, Dennis Dr. Misc, Misc	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss Edith Poland-Jones

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 -AARP AARP Aetna US Healthcare AVESIS BLUCROSS-Perscare BLUECROSS OF CALIFORNIA ANTHEM BLUESHILD CARECRDT DAVIS Department Of Rehabilitation DEPTREHA DISCOUNT Eyecare Plan of America FCE GVA- Non Provider Plan HUMANA Claims IEHP- Inland Impire Health Plan KAISER PERMANENTE LACERA-Cigna LASIK-CO- TLC CO MANAGE M/C Noridian MARCHVISION-MOLINA MED CNTR MEDICAL- (OAS) Medical Eye Services MEDICARE Pametto GBA MERITAIN Health MPLS MISC-Insurances N0NE OPTUM-secure horz United Health AARP PRINCIPAL Life Ins Co Agua Caliente Retail Clerks RR-Medicare RailRoad RTD-EDS SCE-SAFETY GLASSES SO California Pipe Trades SUPERIOR Vision Plan TRICARE Benefits UNITED AMERICAN UNITED HEALTH CARE-AARP Vision Care Pln -Comp Benefits VSP- Vision Service Plan Workmans Compensation
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 -AARP AARP Aetna US Healthcare AVESIS BLUCROSS-Perscare BLUECROSS OF CALIFORNIA ANTHEM BLUESHILD CARECRDT DAVIS Department Of Rehabilitation DEPTREHA DISCOUNT Eyecare Plan of America FCE GVA- Non Provider Plan HUMANA Claims IEHP- Inland Impire Health Plan KAISER PERMANENTE LACERA-Cigna LASIK-CO- TLC CO MANAGE M/C Noridian MARCHVISION-MOLINA MED CNTR MEDICAL- (OAS) Medical Eye Services MEDICARE Pametto GBA MERITAIN Health MPLS MISC-Insurances N0NE OPTUM-secure horz United Health AARP PRINCIPAL Life Ins Co Agua Caliente Retail Clerks RR-Medicare RailRoad RTD-EDS SCE-SAFETY GLASSES SO California Pipe Trades SUPERIOR Vision Plan TRICARE Benefits UNITED AMERICAN UNITED HEALTH CARE-AARP Vision Care Pln -Comp Benefits VSP- Vision Service Plan Workmans Compensation
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 -AARP AARP Aetna US Healthcare AVESIS BLUCROSS-Perscare BLUECROSS OF CALIFORNIA ANTHEM BLUESHILD CARECRDT DAVIS Department Of Rehabilitation DEPTREHA DISCOUNT Eyecare Plan of America FCE GVA- Non Provider Plan HUMANA Claims IEHP- Inland Impire Health Plan KAISER PERMANENTE LACERA-Cigna LASIK-CO- TLC CO MANAGE M/C Noridian MARCHVISION-MOLINA MED CNTR MEDICAL- (OAS) Medical Eye Services MEDICARE Pametto GBA MERITAIN Health MPLS MISC-Insurances N0NE OPTUM-secure horz United Health AARP PRINCIPAL Life Ins Co Agua Caliente Retail Clerks RR-Medicare RailRoad RTD-EDS SCE-SAFETY GLASSES SO California Pipe Trades SUPERIOR Vision Plan TRICARE Benefits UNITED AMERICAN UNITED HEALTH CARE-AARP Vision Care Pln -Comp Benefits VSP- Vision Service Plan Workmans Compensation
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

* Indicates field must be filled out

Are you currently taking any medications?

No Yes

*

If yes, what pharmacy do you use?	What city is it located in?

Please list all your current medications:

*

Are you allergic to any medications?

No Yes

*

If yes, please specify allergies:

Are you diabetic?

No Type 1 Type 2 Other *

Do you have a seizure disorder?

No Yes Other

Height:
ft	in	*

Weight:
lbs	*

WE ARE REQUIRED TO COLLECT THE NEXT 4 ITEMS BY 'THE CENTERS FOR MEDICARE SERVICES'

1) Race:

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White

*

2) Ethnicity:

Non Hispanic or Latino Hispanic or Latino

*

3) Preferred Language:

English French German Spanish

*

4) Smoking Status:

everyday ocassionally former smoker never smoked

*

VISION: * Check if 'none' of the conditions below apply:   Self Family Distance vision blurred Near vision blurred Teary/watery eyes Itchy eyes Dry eyes See floaters or spots Macular Degeneration Glaucoma Other not listed:

IMMUNOLOGIC: * Check if 'none' of the conditions below apply:   Self Family Rheumatoid arthritis Lupus Other not listed:

 

CONSTITUTIONAL: * Check if 'none' of the conditions below apply:   Self Family Weight loss Fever Fatigue Other not listed:

HEMATOLOGIC: * Check if 'none' of the conditions below apply:   Self Family Anemia Lukemia Other not listed:

 

MUSCULOSKELETAL: * Check if 'none' of the conditions below apply:   Self Family Fibromyalgia Osteoarthritis Ankylosing Spondylitis Other not listed:

RESPIRATORY: * Check if 'none' of the conditions below apply:   Self Family Cigarette smoker Asthma Emphysema Other not listed:

 

CARDIOVASCULAR: * Check if 'none' of the conditions below apply:   Self Family Diabetes Hypertension Vascular disease Other not listed:

EAR, NOSE, AND THROAT: * Check if 'none' of the conditions below apply:   Self Family Respiratory tract infection Meds Other not listed:

 

GASTROINTESTINAL: * Check if 'none' of the conditions below apply:   Self Family Crohn's disease Colitis Ulcer Other not listed:

PSYCHIATRIC: * Check if 'none' of the conditions below apply:   Self Family Depression Schizophrenia Other not listed:

 

If this is your first visit to our office, please indicate how you heard about us:

Friend Radio Internet Other

If it was a recommendation, please tell us who it was so we can thank them.

Primary Care Physician:

 

Submit Data