New Patient Form

Patient Information

Title Last First MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Address City State TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY 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	Unknown Single Married Separated Divorced Widowed Child	Occupation
Guardian Name		Employer Name

BILLING INFORMATION

Is the Billing Address Different?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

City

State

TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

ZipCode

Home Phone

Work Phone

Insurance Information

PRIMARY INSURANCE

Insurance Name	None AARP Advantra Freedom Aetna Aetna One Discount American National Life Insurance Company Amerigroup Anthem Health Systems Assurant Health Avesis Bankers Life and Casualty Company Block Vision Blue Cross Blue Shield of Texas CHIPS Christian Fidelity Cigna Coast to Coast Combined Comp Benefits Conseco Health Insurance Co Continental General Insurance Co. Coventry Health and Life Insurance Company Davis Davis Discount Plan Discount Discount Plan Evercare EyeMed EyeMed Discount Plan First Health GEHA Great West Greentree Administrators Group & Pension Administrators Inc. Guarantee Trust Life Ins Co Hartford Life & Accident Insurance Co. Health Choice Health Design Plus Humana Kelsey-Seybold Advantage Kelsey-Seybold Medical Group, PLLC Loyal American MECA Texas Medicaid & HealthCare Partnership Medicare-Trailblazer Health Enterprises, LLC MEGA Life and Health Insurance Company Met Life Mutual of Omaha NALC Health Benefit Plan New Era Life New Insurance Nexcaliber Opticare PacifiCare Physicians Mutual Principle Private Healthcare Systems, Inc Railroad Medicare Renaissance Physicians Organization SafeHealth Life Insurance Company Secure Horizons Spectera SPJST Standard Life Sterling Option I Superior Vision Supplemental Temple Inland Texas Health Spring Texas Health Steps Texas True Choice The Episcopal Church Medical Trust TML Intergovernmental Employee Benefit Pool Tower Life TRICARE for Life UMR Unicare United American Insurance Co United Health Care VSP
Insurance ID
Policy Group ID

I am not the primary on this account

PRIMARY ON ACCOUNT

Name	Last, First MI
Relationship to Insured	Spouse Child Other
Sex	Male Female
Address
City State Zip
Phone Number
Date of Birth
Employer/School

Insurance Continued

SECONDARY INSURANCE

Insurance Name	None AARP Advantra Freedom Aetna Aetna One Discount American National Life Insurance Company Amerigroup Anthem Health Systems Assurant Health Avesis Bankers Life and Casualty Company Block Vision Blue Cross Blue Shield of Texas CHIPS Christian Fidelity Cigna Coast to Coast Combined Comp Benefits Conseco Health Insurance Co Continental General Insurance Co. Coventry Health and Life Insurance Company Davis Davis Discount Plan Discount Discount Plan Evercare EyeMed EyeMed Discount Plan First Health GEHA Great West Greentree Administrators Group & Pension Administrators Inc. Guarantee Trust Life Ins Co Hartford Life & Accident Insurance Co. Health Choice Health Design Plus Humana Kelsey-Seybold Advantage Kelsey-Seybold Medical Group, PLLC Loyal American MECA Texas Medicaid & HealthCare Partnership Medicare-Trailblazer Health Enterprises, LLC MEGA Life and Health Insurance Company Met Life Mutual of Omaha NALC Health Benefit Plan New Era Life New Insurance Nexcaliber Opticare PacifiCare Physicians Mutual Principle Private Healthcare Systems, Inc Railroad Medicare Renaissance Physicians Organization SafeHealth Life Insurance Company Secure Horizons Spectera SPJST Standard Life Sterling Option I Superior Vision Supplemental Temple Inland Texas Health Spring Texas Health Steps Texas True Choice The Episcopal Church Medical Trust TML Intergovernmental Employee Benefit Pool Tower Life TRICARE for Life UMR Unicare United American Insurance Co United Health Care VSP
Insurance ID
Policy Group ID

I am not the primary on this account

PRIMARY ON ACCOUNT

Name	Last, First MI
Relationship to Insured	Spouse Child Other
Sex	Male Female
Address
City State Zip
Phone Number
Date of Birth
Employer/School

TERTIARY INSURANCE

Insurance Name	None AARP Advantra Freedom Aetna Aetna One Discount American National Life Insurance Company Amerigroup Anthem Health Systems Assurant Health Avesis Bankers Life and Casualty Company Block Vision Blue Cross Blue Shield of Texas CHIPS Christian Fidelity Cigna Coast to Coast Combined Comp Benefits Conseco Health Insurance Co Continental General Insurance Co. Coventry Health and Life Insurance Company Davis Davis Discount Plan Discount Discount Plan Evercare EyeMed EyeMed Discount Plan First Health GEHA Great West Greentree Administrators Group & Pension Administrators Inc. Guarantee Trust Life Ins Co Hartford Life & Accident Insurance Co. Health Choice Health Design Plus Humana Kelsey-Seybold Advantage Kelsey-Seybold Medical Group, PLLC Loyal American MECA Texas Medicaid & HealthCare Partnership Medicare-Trailblazer Health Enterprises, LLC MEGA Life and Health Insurance Company Met Life Mutual of Omaha NALC Health Benefit Plan New Era Life New Insurance Nexcaliber Opticare PacifiCare Physicians Mutual Principle Private Healthcare Systems, Inc Railroad Medicare Renaissance Physicians Organization SafeHealth Life Insurance Company Secure Horizons Spectera SPJST Standard Life Sterling Option I Superior Vision Supplemental Temple Inland Texas Health Spring Texas Health Steps Texas True Choice The Episcopal Church Medical Trust TML Intergovernmental Employee Benefit Pool Tower Life TRICARE for Life UMR Unicare United American Insurance Co United Health Care VSP
Insurance ID
Policy Group ID

I am not the primary on this account

PRIMARY ON ACCOUNT

Name	Last, First MI
Relationship to Insured	Spouse 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?

Yes No

Are you having any problems with your present glasses or contacts?	None Blurred Irritating Scratched Broken Old
Have you ever worn contact lenses before?	Yes No
What type of contact lenses have you worn in the past?	Disposables Extended Wear Gas Permeables Gas Perm Bifocals Gas Perm Bitorics Gas Perm FS Toric Monovision - Soft Monovision - Disposables Monovision - Gas Perm No CL Hx Soft Daily Wear Soft Torics
Do you experience dryness or discomfort with contacts?	Yes No
Are you interested in trying contact lenses for the first time?	Yes No
Do you currently wear prescription sunglasses?	Yes No

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