New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Email
Cell Phone: Preferred Contact Method:
Other Phone: Occupation
SSN Employer/School Name
Birthday
Sex Male Female
Marital Status
Primary Doctor
How did you hear about us?:
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
 Last, First, MI
Name:
Phone Number:
Birthday:
SSN:

Medical

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
 Last, First, MI
Name:
Phone Number:
Birthday:
SSN:

Secondary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
 Last, First, MI
Name:
Phone Number:
Birthday:
SSN:

Chief Complaint


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Chief Complaint
Reason for Visit:
Secondary Complaints:

Review of Ocular and Health Systems
Injuries, Infections, Surgeries:

Last Eye Exam: Doctor: Pregnant Or Nursing:

Systemic Medications:

Glaucoma Meds Eye Meds:
Drug Allergies:

Primary Care Physician: Last Visit:
Primary Vision Correction: Age of Glasses:

Family History
NoYes
Blindness
Macular Degeneration
Retinal Detachment
Crossed / Lazy Eye
Cataracts
Glaucoma
Arthritis
Cancer
Diabetes
Heart Disease
Thyroid Disease
Other:

Social History
Occupation: Hobbies:

Tobacco: Type: How Long:
Alcohol: Type: How Long:
Illegal Drugs: Type: How Long:

NOTES:

Review of Systems

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
(Click Here for No to All Below)

GENERAL: Ex. Fever, weight loss, weight gain, fatigue
EAR, NOSE, THROAT: Ex. Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: Ex. High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Ex. Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Ex. Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Ex. Athritis, Joint Pains, Head or Neck Injury
SKIN: Ex. Growths, Rashes, Acne
NEUROLOGICAL: Ex. Headaches, migraines, seizures
PSYCHIATRIC: Ex. Depression, Anxiety, Insomnia
ENDOCRINE: Ex. Thyroid, Diabetes
BLOOD/LYMPH: Ex. Anemia, cholesterol, bleeding problems
GASTROINTESTINAL: Ex. Diarrhea, Constipation, Ulcer, Reflux
ALLERGIC / IMMUNOLOGIC: Ex. Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus

Blood Sugar
A1C

Submit Data

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