New Patient Form

Contact Information

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

* Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
* Email:		* Birthday (mm/dd/yyyy):
Marital Status:	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed

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:

Vision Insurance

Insurance Information

If your vision insurance is separate from your medical insurance, or you have both (vision and medical) please provide this information. If you do not have separate vision insurance, please provide your medical insurance information below.

Insurance Name:	None Blue Cross Blue Shield Davis Vision Harvard Pilgram New Insurance Spectera United Healthcare Other
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:
Employer/School:

Medical Insurance

Insurance Information

Insurance Name:	None Blue Cross Blue Shield Davis Vision Harvard Pilgram New Insurance Spectera United Healthcare Other
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:
Employer/School:

Ocular History

How long since your last eye exam? (3 months, 2 years, never)

Do you wear any of the following?

		Brand:
Contacts:
Glasses:
Bifocals:

Please check all that apply:

	Eye Pain/Sore Eyes:		Tired Eyes:		Eye Discomfort/Irritation:		Loss of Vision:		Red Eye:s
	Eyelid droop:		Burn:		Eyestrain:		Itchy Eyes:		Water:
	Retinal detach:		Headaches:		Macular Deg.:		Glaucoma:		Cataracts:
	Eye injury:		Glare/Halos:		Flashes:		Glasses Wearer:		ContactLens Wearer:
	Eye surgery:		Lazy Eye:		Floaters:		Double vision:		Dry Eyes:

Notes:

Medical History

All Normal

Injuries, Surgeries, Hospitalization:
Pregnant Or Nursing:
Eye medications (please list any you currently taking):
Vitamins:
Medications(please list any you are currently taking):


Drug Allergies: No Known Drug Allergies

Primary Care Physcian: Phone Number: Last Exam:

Other Health Conditions

Do you currently have any of these conditions?     None Apply

CONSTITUTIONAL: (Fever, Fatigue, loss of appetite, unexplained weight loss/gain:)

EAR, NOSE & THROAT: (Ringing in the ears, hearing loss, sinus/nasal congestion, nose bleeds, hoarseness, difficulty swallowing, dry mouth)

HEART OR CIRCULATORY PROBLEMS: (Chest pain, difficulty lying flat, palpitations, other)

LUNGS/BREATHING: (Shortness of breath, cough, coughing blood, wheezing, other)

DIGESTIVE SYSTEM: (Abdominal pain, nausea, vomiting, diarrhea, bloody stools, other)

GENITOURINARY: (Pain on urination, blood or discolored urine, discharge, other)

MUSCULOSKELETAL: (Joint pain, stiffness, swelling, limited movements, other)

SKIN/BREAST: (Rashes, itching, non-healing sores, growths/bumps, discoloration, discharge from breast, other)

NERVOUS SYSTEM: (Headaches, loss of consciousness, numbness or tingling, weakness, tremors, poor balance, other)

PSYCHIATRIC: (Depression, mood swings, anxiety, other.)

ENDOCRINE: (heat or cold intolerance, thinning hair, excess thirst, excess urination, other.)

HEMATOLOGY: (anemia, bleeding gums, unexplained bruising, delayed clotting, other.)

ALLERGIC/IMMUNOLOGIC: (swollen lymph nodes, itching, sneezing, runny nose/eyes)

STD History:

Additional Info:

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