New Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
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. Strum, O.D., Mark
Dr. Gallegos, O.D., Amy
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
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
Aetna
Anthem
Blue Cross Blue Shield
Cigna
CNIC Health Solutions
DAVIS VISION
EyeMed
Great West Health
health Design Plus
Humana
Madison Street
Medicare
medico
Mutual of Omaha
Private Pay
Rocky Mountain UFCW
Secure Horizons
spectera
transamerica
Tricare
UMR
United Health Care
VCPN
Vision Care Plan (VCP)
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
Aarp
Aetna
Anthem
Blue Cross Blue Shield
Cigna
CNIC Health Solutions
DAVIS VISION
EyeMed
Great West Health
health Design Plus
Humana
Madison Street
Medicare
medico
Mutual of Omaha
Private Pay
Rocky Mountain UFCW
Secure Horizons
spectera
transamerica
Tricare
UMR
United Health Care
VCPN
Vision Care Plan (VCP)
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
Aarp
Aetna
Anthem
Blue Cross Blue Shield
Cigna
CNIC Health Solutions
DAVIS VISION
EyeMed
Great West Health
health Design Plus
Humana
Madison Street
Medicare
medico
Mutual of Omaha
Private Pay
Rocky Mountain UFCW
Secure Horizons
spectera
transamerica
Tricare
UMR
United Health Care
VCPN
Vision Care Plan (VCP)
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
Age
Occupation:
Referred By:
Referring Doctor:
Family Patients:
Hobbies:
Mood
cheerful
subdued
Ever Worn Contact Lenses?
Yes
No
Are You Interested in Contact Lenses?
Affect
oriented to time, place, date
confused
forgetful
Type of CLs worn in past:
Disposables
Extended Wear
Gas Permeables
Gas Perm Bifocals
Monovision - Soft
Monovision - Disposables
Monovision - Gas Perm
No CL Hx
Soft Torics
Back up specs for cls?
Yes
No
Primary Vision Correction:
Single Vision
Bifocals
Contacts
Contacts - Mono
None
Progressives
Trifocals
Hours on computer
< 2 hours
> 4 hours
> 8 hours
Problems with glare?
Yes
No
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
Ocupress
Pilo Gel
Propine
Polytrim
Pred Mild
Pred Forte
Patanol
Timoptic .25%
Timoptic .5%
Tobradex
Vigamox
Voltaren
Xalatan
Last Eye Doctor:
Primary Care Physician:
Systemic Meds:
Family Med History:
Artheritis
Cancer
Diabetes I
Diabetes II
Hypertension
Hypercholesterolmia
Heart Dx
Good health reported
-DM, -HTN, -heart disease
Family Eye History:
-armd, -glaucoma
Amblyopia
Cataracts
Glaucoma
Macular Degeneration
Retinal Detachment
Weak Eye
Lazy Eye
No Known
Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Pregnant,Nursing,HIV+
Allergies:
KNMA
No Known
Codine
Erythromycin
Iodine
Pollen
PCN
Sulfa
Tetnus
Tetracycline
NOTES:
No Current Medications:
No Known Drug Allergies
Submit Data
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