New Patient Form

Demographics

Title First Last MI Suffix Nickname Pronoun MR. MRS. MS. DR. REV. MISS. MASTER he/him/his she/her/hers they/them/theirs

Address:
City:		State/ZipCode	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

Home Phone:		Work Phone:
Other Phone:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday
Gender Assigned at birth	Male Female	Gender Identity
Marital Status	Unknown Single Married Separated Divorced Widowed Child DOMESTIC PARTNER	Employment Status	Employed Full-Time Student Part-Time Student
Employer/School Name		Primary Doctor	No Doctor Assigned Dr. DUKE, O.D., ROGER
Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
MR. MRS. MS. DR. REV. MISS. MASTER

Address

City	State	ZipCode
	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

Home Phone:
Work Phone:

Medical History

Emergency Contact Person: Emergency Phone #:

Referred By:

Insurance Friend/Family Website/Internet Yellow Pages Walk-by/Drive-by

Referring Doctor:

List Any Family Members Who Are Patients:

Hobbies:	Occupation

Interested In Contact Lenses?

Yes No

Ever Worn Contact Lenses?

Yes No

Type of Contacts Worn: Disposable Soft, Dailies, Torics, Multtifocals, RGPs,etc

Do You Wear Glasses When Not Wearing Contacts?

Yes No

Primary Vision Correction:

None Glasses Contacts Glasses and Contacts

Do You Wear Sunglasses?

Yes No

Interested in Laser Vision Correction?

No Yes

PATIENT EYE HISTORY: Please list all Injuries,Infections,Surgeries and Diseases of your eyes and dates of occurrence.

List All Current Eye Medications:

Name of Last Eye Doctor and Phone #:

Name of Last Primary Care Physician:	Phone Number:
Endocrinologist:	Phone Number:

List All Other Current Medications (Non-Eye)::

PATIENT MEDICAL HISTORY: Diabetes,High Blood Pressure,Cancer,Heart Disease or Other Conditions.

FAMILY MEDICAL HISTORY: Diabetes,High Blood Pressure,Cancer,Heart Disease or Other Conditions.

FAMILY EYE HISTORY: Glaucoma,Macular Degeneration,Retinal Detach,Cataract or Other Conditions.

List All Medications That You Are Allergic To:

SOCIAL HISTORY: Please answer the question concerning alcohol,tobacco or illegal drug use

I do not use alcohol,tobacco or illegal drugs I use alcohol I use tobacco I use alcohol and tobacco

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