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:

Vision Insurance

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:

Medical Insurance

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:

Other Insurance

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:

Chief Complaint


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Reason for Visit:

REVIEW OF OCULAR SYSTEM:

Ocular History Eye Meds: Last Eye Exam:

Family Ocular History:

Do you have a family history of the following?

Glaucoma: Cataracts: Macular Degen: Retinal Detach: Crossed / Lazy:

Primary Vision Correction: Do you have a back-up pair of glasses? Do you want new glasses?

What type of contact lenses have you worn in the past? What type of cleaner do you use?
How often do you dispose of your contacts? What is the age of your current pair?
How often do you wear your contacts? How many hours of comfortable wear do you get out of your contacts?

NOTES:

Race: Ethnicity: Preferred Language:

Medical History


Please choose from the menu options or select "Other" to type in multiple choices and/or your own text. Thank you!
REVIEW OF SYSTEMS

Do you have problems in the following areas?

ALLERGIC / IMMUNOLOGIC (seasonal, pets, foods):
BONES, JOINTS, MUSCLES (osteopororis, arthritis):
CARDIOVASCULAR (heart, cholestorol):
CONSTITUTIONAL / GENERAL:
EAR, NOSE, THROAT (sinus):
ENDORCRINE (diabetes, thyroid):
GASTROINTESTINAL (digestive conditions):
GENITAL, KIDNEY, BLADDER:
HEME / BLOOD / LYMPH (anemia, Lupus):
INTEGUMENTARY / SKIN
NEUROLOGICAL (multiple sclerosis, migraines):
PSYCHIATRIC (depression, anxiety, ADHD):
RESPIRATORY (COPD, asthma):

PATIENT MEDICAL HISTORY

Primary Care Physcian: Last Visit:

Current Medications:          No meds


Drug Allergies:                   No known drug allergies


Vitamins: Over The Counter Meds:

Injuries, Surgeries, Hospitalization

FAMILY MEDICAL HISTORY


SOCIAL HISTORY

Occupation: Hobbies:

Smoking Status Type: How Long:
Alcohol:

Submit Data

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