New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor 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:
SSN:
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:
SSN:
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:
SSN:
Employer/School:

Medical History

Referred By:
Referring Doctor:
Family Patients:
Hobbies:
Interested In Contact Lenses?
Ever Worn Contact Lenses?
Type of CLs worn in past:
Primary Vision Correction:
Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal
Eye Meds:
Last Eye Doctor:
Primary Care Physician:
Systemic Meds:
Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Smoke,Pregnant,Nursing,HIV+
Family Med History:
Family Eye History:
Medication and Seasonal Allergies:
NOTES/SOCIAL HISTORY

Submit Data

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