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New Patient Forms


We are excited to welcome you to our practice! Please take a few minutes to fill this form out as completely as possible.

Demographics


Patient Information
TitleLegal FirstLastPreferred Name
Address:
City: State/ZipCode
Home Phone:
Cell Phone: Preferred Contact Method:
Last 4 of SSN Email
Birthday Occupation
Sex
Marital Status



Dependents


(Please list First, Last and date of birth.)

Primary Vision

Insurance Information
*Please text or call to confirm your doctor is in network with your plan 512-494-5350*
Insurance Name:
ID #:

Not Primary on Account:
Primary on Account:
Name:Last, First
Relationship to Insured:
Sex:
Birthday:
Last 4 of SSN:

Primary Medical

Insurance Information
*Please text or call to confirm your doctor is in network with your plan 512-494-5350*
Insurance Name:
ID # (incld. any numbers):
Group #:

Not Primary on Account:
Primary on Account:
Name:Last, First
Relationship to Insured:
Sex:
Birthday:
Last 4 of SSN:

Medical History


Reason for Visit: Last Eye Exam: Previous eye doctor:
Have you worn contacts in the past?: Type of contacts worn in the past:
Do you have back up glasses? Primary vision correction?
Want new glasses?
Interested in Lasik? Hours on the computer?

Primary care provider: Endocrinologist:
Medical History: Ocular History:
Medications: Supplements/drops:
Drug Allergies:


Diabetes: Year Diagnosed: HbA1C: Taken:

Glucometry: Taken:

Please list all that apply for each (M/F/S/GP):
Glaucoma:
Cataracts:
Macular Degen.:
Retinal Detach.:
Other Family Ocular History:

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