New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

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:
Employer/School:

Secondary

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:
Employer/School:

Tertiary

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:
Employer/School:

Medical History

Preferred Name
Age
Sex
Reason for Visit
Occupation
Hobbies
Interested in Contact Lenses?Previous CL Wearer?If so, did you sleep in your CL?If not, would you like to?
Age of current glasses
Completely satisfied with current glasses?Interested in less glare?Interested in thinner / lighter lenses?Spend time on a computer?
Social History
Visual difficulty while night driving?Spned much time driviing, boating, golfing, skiing?Tobacco Use?Alcohol Use?Drug Use?
If Yes, how much?
HypertensionDiabetesHigh CholesterolHeart DiseaseCancerThyroid ProblemHeadaches
Other
GlaucomaMacular DegenerationDry Eye SyndromeRetinal DetachmentCataractsCrossed EyeCorneal UlcerCorneal AbrasionDouble VisionLight SensitivityItchy EyesFlashes of LightFloatersWatery EyesBurning EyesEye PainEye Strain
Systemic Medications
Ocular Medications
Allergies
Surgeries (Year)
HypertensionDiabetesHeart DiseaseCancerBlindnessGlaucomaMacular DegenerationLazy EyeRetinal ProblemsCorneal Problems
If Yes, then who?

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