New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev.

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:		Alerts:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Lee, Aaron Dr. Pierce, Jordan	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

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:

Insurance 1

Insurance Information

Insurance Name:	None Aetna Block Vision Blue Cross Blue Shield of Texas CHIPs - Opticare/Cook Childrens/Superior Foster/Star Plus/Bravo Health Cigna Compbenefits/Humana Vision EyeMed Medicaid Medicare NVA Optum Health (Spectera) PHCS/Multiplan Superior United Healthcare Vision USA VSP
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:

Insurance 2

Insurance Information

Insurance Name:	None Aetna Block Vision Blue Cross Blue Shield of Texas CHIPs - Opticare/Cook Childrens/Superior Foster/Star Plus/Bravo Health Cigna Compbenefits/Humana Vision EyeMed Medicaid Medicare NVA Optum Health (Spectera) PHCS/Multiplan Superior United Healthcare Vision USA VSP
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:

Insurance 3

Insurance Information

Insurance Name:	None Aetna Block Vision Blue Cross Blue Shield of Texas CHIPs - Opticare/Cook Childrens/Superior Foster/Star Plus/Bravo Health Cigna Compbenefits/Humana Vision EyeMed Medicaid Medicare NVA Optum Health (Spectera) PHCS/Multiplan Superior United Healthcare Vision USA VSP
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

______________________________________________________________________________________________________ __________
PERSONAL and SOCIAL HISTORY:
Referring Doctor:
Family Patients:
Referred By:
Insurance Friend/Family Website/Internet Yellow Pages Walk-by/Drive-by

Primary Vision Correction:
Prev CL Wearer
Single Vision Contacts Progressives Bifocals Contacts - Mono Trifocals None
Interested In Contact Lenses?
Interested in Laser Vision Correction?
Type of CLs worn in past:
No CL Hx Soft Sphere Soft Torics Soft - Monovision Soft Bifocals RGP Sphere RGP Bifocals RGP Bitorics RGP Front Surface Toric
Sunspecs?

Hobbies:

Back up specs for cls?
SV BIF FT PAL TRI SV Read OTC Read
_______________________________________________________________________________________
MEDICAL PERSONAL AND FAMILY HISTORY:
OCULAR Hx:

Last Eye Doctor:
PCP:
OCULAR MEDS:

SYSTEMIC MEDS:

FMH:

MED Hx: HAs,Arthritis,Asthma,Diabetes,HTN,Thyroid,Pregnant,Nursing,HIV+

FOH:

ALLERGIES Medication and Seasonal:

NOTES/SOCIAL HISTORY