New Patient Form

Demographics

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

CityStateZipCode
Home Phone:
Work Phone:

Primary

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:

Secondary

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:

Tertiary

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:

Ocular History

Last Eye Exam:
Doctor:
or Place:
Ocular History: List of Surgeries, Amblyopia/Lazy Eye, Stabismus/Eye Turn, Significant Trauma, Cataracts, Glaucoma, Macular Degeneration, History of Wearing Contacts
Do you use any of the following eye medications?
Primary Vision Correction:
If you primarily wear contact lenses, do you have back up glasses?
Are you planning to get new glasses?
FAMILY OCULAR HISTORY:
Glaucoma:
Cataracts:
Macular Degeneration:
Retinal Detach:
Crossed / Lazy:
CONTACT LENS INFORMATION: Check this box if you want a Contact Lens Evaluation at your Exam
What is your current brand or type of contact lenses?
Other:
Distance Only Monovision Multifocal
How would you rate the comfort?
How often do you sleep in your contact lenses?
How often do you throw away your contacts and put in a new pair?

Medical History

Occupation:
Race: Required to ask per the Affordable Care Act
Preferred Language: Required to ask per the Affordable Care Act
Ethnicity: Required to ask per the Affordable Care Act
Who is your Primary Care Physcian:
Last Visit to Primary Care Doctor:
Problems List: Examples include Diabetes, Hypertension, High Cholesterol, Multiple Sclerosis, Sarcoidosis, Lupus, Osteo Arthritis, Rheumatoid Arthritis, Cancer, Hypothyroid, Hyperthyroid, Cancer, COPD, Asthma, Sickle Cell
Medications: Please list all current medications and their dosages
No current medications
OTC:
Vitamins:
Allergies: Please list all current known allergies, and your reaction to them
No Known Allergies
Pregnant Or Nursing:
Any Complications from Pregnancy:
Significant Injuries, Surgeries, Hospitalization
Smoking Status:
How Long have or did you smoke for:
FAMILY MEDICAL HISTORY:
Examples: Diabetes, Heart Disease, Cancer, Kidney, Thyroid, Other:
Family Medical History
Family Medical Histor
Family Medical History
Family Medical History
Family Medical History

Submit Data

After Completing All Forms Submit Data on Final Tab