New Patient Form


City: State/ZipCode
*Home Phone: Work Phone:
Other Phone:
*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 as above - If not please fill out the information below?

Home Phone:
Work Phone:

Medical History

Last Eye Dr. Seen:
How long ago?
Who is your primary care physician?:
Primary Care Physician City:
Primary Care Physician State:
Primary Care Physician Phone:
Primary Care Physician Fax:
Approx date of last visit to your physician:
What was the reason for that visit?:
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


Social History

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 Pregnant or Nursing?


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 (Hyperthyroid, Hypithyroid, Hashimoto's, Grave's disease, Myasthenia Gravis): If "yes" please explain:
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, Rheumatoid Arthritis, Lupus, Sjogren's): If "yes" please explain:
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
Macular Degeneration
Retinal Detachment
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