New Patient Form

Insurance

Primary Insurance Information

Insurance Name:	None Aetna Avesis BCBSAZ EyeMed Vision Care Noridian Medicare Selfpay-prompt pay Superior Vision Services VSP- Miscellaneous Miscellaneous AAA AAA Discount AARP Discount Adminstrative Enterprises,Inc. Aetna Vision One Discount AZ Pipe Trades BCBS- Other Discount Eye Med Plan FEG Family Discount First Health GOS HumanaVCP Mall Employee 10% Disc. Medical Eye Services Mutual of Omaha Discount None Palmetto GBA - Rail Road Medicare Southwestern Eye Center Unicare
Insurance ID:
Insurance Policy Group:

Name of Insured is Different than Patient

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Address:
City:	State: Zip:
Employer:

Secondary Insurance Information

Insurance Name:	None Aetna Avesis BCBSAZ EyeMed Vision Care Noridian Medicare Selfpay-prompt pay Superior Vision Services VSP- Miscellaneous Miscellaneous
Insurance ID:
Insurance Policy Group:

Name of Insured is Different than Patient

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Address:
City:	State: Zip:
Employer:

Visual History

Do you have a history of any of the following?

      Set all to no

	YES	NO
Cataracts
Glaucoma
Blindness
Keratoconus
Macular Degeneration
Retinal Detachment
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Blurred Vision
Double Vision
Flashing lights
Frequent styes
Eyes feel dry
Eyes itch
Eyes burn
Eyes tear
Floaters
Headaches
Eyes frequently red
Eyes feel sandy/gritty
Eyes "hurt" or "tired"
Halos around lights
Bothered by light / sun light

Have you had cataract surgery?
Please note the year(s):

Right eye:
Left eye:

Medical History

Do you have, or ever had, any CHRONIC problems in the following areas?

      Set all to no

	YES	NO
Migraines
Multiple Sclerosis
Diabetes
Thyroid problems
Arthritis
Allergies/Hay fever
Asthma
Emphysema
High blood pressure
Stroke
Anemia
Cancer

Family History

Any history of the following in any family members (parents, grandparents, siblings, children)?

      Set all to no

	YES	NO	RELATIONSHIP TO PATIENT
Poor Vision			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Blindness			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Eye turn (Strabismus)			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Lazy Eye (Amblyopia)			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Glaucoma			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Cataracts			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Macular Degeneration			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Retinal Detachment/Disease			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Cancer			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Diabetes			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
High Blood Pressure			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Stroke			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Thyroid Disease			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather
Other Inherited Disease			Mother Father Both Parents Sister Brother Aunt Uncle Grandmother Grandfather

If yes, what disease?

List the medications you are currently taking - including over the counter meds.
You are welcome to provide us with a list at the time of your visit.

Please list any medications you are allergic to:

Finish Submitting

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