New Patient Form

Patient Information

TitleLastFirstMISuffixNickname
Address
City State Zip Code
Home Phone Work Phone
Other Phone SSN
Email Date of Birth
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Occupation
Guardian Name Employer Name
BILLING INFORMATION Is the Billing Address Different?

TitleFirstLastMISuffix
Address
City StateZipCode
Home Phone Work Phone

Insurance Information

PRIMARY INSURANCE
Insurance Name
Insurance ID
Policy Group ID
I am not the primary on this account
PRIMARY ON ACCOUNT
NameLast, First MI
Relationship to InsuredSpouse Child Other
Sex Male Female
Address
City State Zip
Phone Number
Date of Birth
Employer/School

Insurance Continued

SECONDARY INSURANCE
Insurance Name
Insurance ID
Policy Group ID
I am not the primary on this account
PRIMARY ON ACCOUNT
NameLast, First MI
Relationship to InsuredSpouse Child Other
Sex Male Female
Address
City State Zip
Phone Number
Date of Birth
Employer/School

TERTIARY INSURANCE
Insurance Name
Insurance ID
Policy Group ID
I am not the primary on this account

PRIMARY ON ACCOUNT
NameLast, First MI
Relationship to InsuredSpouse Child Other
Sex Male Female
Address
City State Zip
Phone Number
Date of Birth
Employer/School

Medical History

Who may we thank for referring you to our office?
Are any other members of your family currently patients with us?

Do you participate in a Flexible Spending Account?

Are you having any problems with your present glasses or contacts?
Have you ever worn contact lenses before?
What type of contact lenses have you worn in the past?
Do you experience dryness or discomfort with contacts?
Are you interested in trying contact lenses for the first time?
Do you currently wear prescription sunglasses?
If applicable, please tell us how often you smoke and/or drink:

Please list any medications you are currently taking (prescription or over-the-counter):
Please list any medications you are allergic to:

Please list and explain any of the following that you have ever been diagnosed with or treated for:
Allergies, Asthma, Arthritis, Heart Disease, Cholesterol, Diabetes,
Kidney Disease, Thyroid Disease, High Blood Pressure, Cancer, Nerves
Please list and explain any family history of any of the above:

Please list and explain any of the following that you are experiencing or have ever experienced in the past:
Trouble Seeing at Night, Sunlight Sensitiviy, Floaters/Spots, Double Vision, Crossed Eye, Itchiness,
Flashes of Light, Blurry Vision, Headaches, Burning, Grittiness, Tearing, Eye Infection, Eye Injury,
Cataracts, Macular Degeneration, LASIK or RK, Lazy Eye, Retinal Detachment, Iritis/Uveitis, Glaucoma
Please list and explain any family history of any of the above:

Review of Systems

Please list any general health information you feel we should be aware of. If none, type "None":
(i.e.: Unexpected Weight Loss or Gain, Hard of Hearing, Chronic Fever)

Please list any ear, nose, or throat problems that you currently have. If none, type "None":
(i.e.: Hearing Loss, Sinus Problems, Ear Ache, Sore Throat, Cough)

Please list any cardiovascular problems that you currently have. If none, type "None":
(i.e.: High Blood Pressure, Chest Pain, Irregular Heart Beat)

Please list any respiratory problems that you currently have. If none, type "None":
(i.e.: Shortness of Breath, Wheezing, Coughing, Congestion)

Please list any urinary, kidney, or bladder problems that you currently have. If none, type "None":
(i.e.: Frequent or Painful Urination, Blood in the Urine, Impotence)

Please list any muscle, bone, or joint problems that you currently have. If none, type "None":
(i.e.: Arthritis, Joint Pain, Stiffness, Swelling, Muscle Aches, Cramps)

Please list any skin problems that you currently have. If none, type "None":
(i.e.: Rashes, Excessive Dryness, Warts, Acne)

Please list any neurological problems that you currently have. If none, type "None":
(i.e.: Numbness, Weakness, Headaches, Dizziness, Seizures)

Please list any psychiatric problems that you currently have. If none, type "None":
(i.e.: Depression, Anxiety, Insomnia)

Please list any endocrine problems that you currently have. If none, type "None":
(i.e.: Diabetes, Hypothyroid)

Please list any blood or lymph node problems that you currently have. If none, type "None":
(i.e.: Anemia, Bleeding, Cholesterolemia)

Please list any allergic or immunologic problems that you currently have. If none, type "None":
(i.e.: Hives, Lupus, Redness, Swelling, Sneezing, Itching)

Submit Data