New Patient Form

Patient Info

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
Email
Birthday Occupation
Sex 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 realted 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

After Completing All Forms Submit Data on Final Tab