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:

Medical

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 Supplement

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:

Vision

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 History

Nickname:
Last Eye Dr. Seen:
How long ago?
Who is your primary care physician?:
Approx date of last visit to your physician:
What was the reason for that visit?:
Race:
Ethnicity:
Preferred Language:

List all the medications you are currently taking, including over the counter meds: No current medications


List your allergies (if any). Include allergies to medications: No known drug allergies


NOTES:


Social History

Occupation:
Hobbies:
Describe your amount and frequency of alcohol consumption (if any):
Do you use marijuana or recreational drugs? If so, list them here:
Smoking Status:

Do you have any infections diseases (including STDs)? Example: Gonorrhea, Syphilis, Hepatitis, HIV, Tuberculosis. If so, list them here:


Are you interested in Contact Lenses?
Are you interested in LASIK refractive surgery?
Are you interested in Latisse for eyelash elongation?
Are you Pregnant or Nursing?

PATIENT OCULAR HISTORY:

List any eye drops that you take including over the counter drops (unless you already listed them in the medication section):


Please list current or past eye disorders including: crossed eyes, lazy eye, drooping eyelid, glaucoma, cataracts, macular degeneration, retinal detachment, eye infection, eye injury:


Review of Systems


REVIEW OF SYSTEMS: Do you currently, or have you ever had, any problems in the following areas?

CONSTITUTIONAL (Fever, Weight Loss/Gain): If "yes" please explain:
INTEGUMENTARY (Skin): If "yes" please explain:
NEUROLOGICAL (Headaches, Migraines, Seizures): If "yes" please explain:
EYES (Loss of side vision, double vision, dryness, irritation, flashes and floaters): If "yes" please explain:
ENDOCRINE (thyroid):
EAR, NOSE, MOUTH, THROAT (Allergies/hay fever, sinus congestion): If "yes" please explain:
RESPIRATORY (Asthma, chronic bronchitis, COPD): If "yes" please explain:
CARDIOVASCULAR (Diabetes, heart pain,
high blood pressure, heart attack/stroke, high cholesterol):
If "yes" please explain:
BONES/JOINTS/MUSCLES (Arthritis, muscle/joint pain):
BEHAVIORAL HEALTH (Anxiety, depression, mood disorder, ADHD): If "yes" please explain:

Use the drop down menus below to indicate if any of your family members have any of the following conditions:

Crossed / Lazy Eye
Glaucoma
Macular Degeneration
Retinal Detachment
Arthritis
Cancer
Diabetes
Heart Attack / Stroke
High Blood Pressure
Thyroid Disease

Notes-- you may tell us anything else about your eye or health history here:


Submit Data

After Completing All Forms Submit Data on Final Tab