New Patient Form

Demographics

TitleFirstLastMISuffixNicknamePronoun
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday
Gender Assigned at birth Male Female Gender Identity
Marital StatusEmployment Status Employed Full-Time Student Part-Time Student
Employer/School NamePrimary Doctor
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical History

Emergency Contact Person: Emergency Phone #:
Referred By:
Referring Doctor:
List Any Family Members Who Are Patients:
Hobbies:Occupation
Interested In Contact Lenses?
Ever Worn Contact Lenses?
Type of Contacts Worn: Disposable Soft, Dailies, Torics, Multtifocals, RGPs,etc
Do You Wear Glasses When Not Wearing Contacts?
Primary Vision Correction:
Do You Wear Sunglasses?
Interested in Laser Vision Correction?
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

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