New Patient Form

Patient Info

TitleLegal First NameLegal Last NameMISuffixName (if different from legal) Pronoun
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
Birthday Occupation
Assigned Sex (for insurance purposes) Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor

Medical History

What is the reason for your eye exam?

Do you use any of the following types of vision correction?
Occupational glasses Sports Eyewear Sunglasses Contact Lenses Glasses
During a typical day, how many hours do you spend on the following activities:
Computer, Smartphone, Reading, and other near vision tasks:

Driving and other distance vision tasks:

Do you have problems with glare or night vision?

How could your current glasses be improved?

How could your current contact lenses be improved?

Ocular History: List any surgery, injury, infection, or eye disease

Family Ocular History: List eye disease and related family member

Medications: List current prescription and OTC medications

Medical History: List all diseases and medical problems

Allergies: List all drug and environmental allergies

Please list sports, hobbies, and recreational activities:

How did you learn about our office?

Submit Data

Financial Responsibility Statement

Your insurance is a method for you to receive reimbursement for fees you have paid to Oculus Eyecare, Inc. for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages based on your contract with them, not our office. It is your responsibility to pay in advance for the deductible, coinsurance, or any other balances not paid for by your insurance. We will assist you in receiving reimbursement as much as possible, but you are responsible for your bill. By signing this you authorize payment of these benefits directly to Oculus Eyecare, Inc. on your behalf for any services and materials furnished. And you agree to be financially responsible for all charges.

Patient / Guardian Signature: Date:

Acknowledgement of Receipt of Notice of Privacy Practices

In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct healthcare operations involving our office. The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. By signing this statement I acknowledge that I have received the Notice of Privacy Practices from Oculus Eyecare, Inc.

Patient / Guardian Signature: Date:
If signing as a representative, describe relationship to the patient:

* I agree to digitally receive my contact lens prescription via email, text, or online portal.

After Completing All Forms Submit Data on Final Tab