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
Unknown
Single
Married
Separated
Divorced
Widowed
Child
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Le, Thanh
Dr. Tran, Michael
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:
Primary
Insurance Information
Insurance Name:
None
EyeMed
VSP
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
EyeMed
VSP
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
EyeMed
VSP
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
Referred By:
Insurance
Friend/Family
Website/Internet
Yellow Pages
Walk-by/Drive-by
Which doctor referred you to us:
Do you have any hobbies:
Interested In Contact Lenses?
Yes
No
Ever Worn Contact Lenses?
Yes
No
Type of CLs worn in past:
No CL Hx
Disposables
Extended Wear
Gas Permeables
Gas Perm Bifocals
Gas Perm Bitorics
Gas Perm FS Toric
Monovision - Soft
Monovision - Disposables
Monovision - Gas Perm
Soft Daily Wear
Soft Torics
Back up specs for cls?
Yes
No
Primary Vision Correction:
None
Bifocals
Contacts
Contacts - Mono
Progressives
Single Vision
Trifocals
Sunspecs?
Yes
No
Interested in Laser Vision Correction?
Not Interested
Yes
Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal
None
Abrasion
Blind Eye
Blepheroplasty
Cataract - OU
Cataract - OD
Cataract - OS
Conjunctivitis
Glaucoma
IOL - OU
IOL - OD
IOL - OS
Metal in Eye
Ptosis
Retinal Detach
Weak Eye
Lazy Eye
Eye Meds:
None
Acular
Artificial Tears
Betoptic-S .25%
Betoptic .5%
Betagan
Erythromycin
FML
FML Forte
Gentamicin
Neosporin
Ocupress
Pilo Gel
Propine
Polytrim
Pred Mild
Pred Forte
Patanol
Timoptic .25%
Timoptic .5%
Tobradex
Voltaren
None
Xalatan
Last Eye Doctor:
Primary Care Physician:
Systemic Meds:
Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Smoke,Pregnant,Nursing,HIV+
Family Med History:
None Known
Artheritis
Cancer
Diabetes I
Diabetes II
Hypertension
Hypercholesterolmia
Heart Dx
None
Family Eye History:
None
Amblyopia
Cataracts
Glaucoma
Macular Degeneration
Retinal Detachment
Weak Eye
Lazy Eye
Medication and Seasonal Allergies:
None
Codeine
Erythromycin
Iodine
NKDA
PCN
Pollen
Sulfa
Tetanus
NOTES/SOCIAL HISTORY
Submit Data
After Completing All Forms Submit Data on Final Tab