New Patient Form

Patient Info

Title Legal First Name Legal Last Name MI Suffix Name (if different from legal)  Pronoun Mr. Mrs. Ms. Dr. Rev. Mx.   he/him/his she/her/hers they/them/theirs

Address:
City:		State/ZipCode	WA 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 TX UT VT VI VA 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
Email
Birthday		Occupation
Assigned Sex (for insurance purposes)	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child Domestic Partnership	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Woerner, Jeff

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.