New Patient Form

Demographics

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

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:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Kamnetz, Gregg Dr. Le, Thi Dr. Tam, Collin Dr. Franklin, Sonja Dr. Hearn, Elisa Dr. Maybury, Richard Dr. Tran, Tam Dr. Cherry, Lynea Dr. Solly O.D., Pam Dr. Poirrier, Shelley Dr. Wilkins O.D., Tom Dr. Wampler, Kimberly Dr. Rhodes, Courtney Dr. Berg, Sarah Dr. Kamath, Sandya Dr. Thomas O.D., Peter Dr. Henson, Lauren Dr. Brueggemann O.D., Jeremy Dr. Pak O.D., Linda Dr. Barai, Manoshi Dr. Shafer OD, Kathleen Dr. Guenthner, Nancy Dr. Weeden O.D., Steven Dr. Fuller O.D., Bridgette Dr. Kodukula, Dipa Dr. Tomeff, Tamatha Dr. Kerr O.D., Carolyn Dr. Colorado, Stephanie Dr. Haselhorst O.D., Erik Dr. Sturm O.D., Mark Dr. Miller, Dina Dr. Barnett, Cary Dr. Bockin O.D., Donald Dr. Nakatsuchi, Don Dr. Stola, Katherine Dr. Bellingrath, Edward Dr. Ramp, Robert	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

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:

Primary

Insurance Information

Insurance Name:	None 60054 AETNA 61101 HUMANA 62308 Cigna 87098 Avesis 87726 UNITED HEALTHCARE Always Vision ANTHEM HEALTH PLANS OF TX DARS DAVIS VISION EYEMED VISION CARE Eyetopia Vision Care HMO BLUE MEDICAID HMO BLUE MEDICAID [AECC OF TX] ICON LASER EYE CENTERS INSURED VISION LIFE RE LIONS CLUB MAJESTIC MEDI MET MEDICAID-NHIC NVA PCA PCA STAR MEDICAID PHCS Safeguard Salvation Army Voucher SAN MARCOS TREATMENT CENTER SB900 BCBS OF TX Scott and White SMTX0 MEDICARE OF TX Spectera / Optum Health / UHC Vision SPRNT Block Vision Inc. SUPERIOR VISION TEXAS COMMISSION FOR THE BLIND TEXAS MUNICIPLE LEAGUE TEXAS OPTOMETRIC ASSOCIATION TLC, STEVEN DELL, M.D. Traveller's Workman's Compensation TRICARE MILITARY Vision Care Plan VISION SERVICE PLAN
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:	None 60054 AETNA 61101 HUMANA 62308 Cigna 87098 Avesis 87726 UNITED HEALTHCARE Always Vision ANTHEM HEALTH PLANS OF TX DARS DAVIS VISION EYEMED VISION CARE Eyetopia Vision Care HMO BLUE MEDICAID HMO BLUE MEDICAID [AECC OF TX] ICON LASER EYE CENTERS INSURED VISION LIFE RE LIONS CLUB MAJESTIC MEDI MET MEDICAID-NHIC NVA PCA PCA STAR MEDICAID PHCS Safeguard Salvation Army Voucher SAN MARCOS TREATMENT CENTER SB900 BCBS OF TX Scott and White SMTX0 MEDICARE OF TX Spectera / Optum Health / UHC Vision SPRNT Block Vision Inc. SUPERIOR VISION TEXAS COMMISSION FOR THE BLIND TEXAS MUNICIPLE LEAGUE TEXAS OPTOMETRIC ASSOCIATION TLC, STEVEN DELL, M.D. Traveller's Workman's Compensation TRICARE MILITARY Vision Care Plan VISION SERVICE PLAN
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:	None 60054 AETNA 61101 HUMANA 62308 Cigna 87098 Avesis 87726 UNITED HEALTHCARE Always Vision ANTHEM HEALTH PLANS OF TX DARS DAVIS VISION EYEMED VISION CARE Eyetopia Vision Care HMO BLUE MEDICAID HMO BLUE MEDICAID [AECC OF TX] ICON LASER EYE CENTERS INSURED VISION LIFE RE LIONS CLUB MAJESTIC MEDI MET MEDICAID-NHIC NVA PCA PCA STAR MEDICAID PHCS Safeguard Salvation Army Voucher SAN MARCOS TREATMENT CENTER SB900 BCBS OF TX Scott and White SMTX0 MEDICARE OF TX Spectera / Optum Health / UHC Vision SPRNT Block Vision Inc. SUPERIOR VISION TEXAS COMMISSION FOR THE BLIND TEXAS MUNICIPLE LEAGUE TEXAS OPTOMETRIC ASSOCIATION TLC, STEVEN DELL, M.D. Traveller's Workman's Compensation TRICARE MILITARY Vision Care Plan VISION SERVICE PLAN
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

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Medical History

Physician:

Referred By:

Height:

ft

in

Weight (lbs):

Diabetes?

Type 1 Type 2 None

Year Diagnosed:

Smoking Status:

Current Smoker Never Smoker Former Smoker Other

Hx of Alcohol:

Yes No Other

Hx of Other:

Yes No Other

Preferred Language:

English Spanish Other

Race:

American Indian/Alaskan Native Asian African American Native Hawaian/Pacific Islander White Other

Ethnicity:

Hispanic Or Latino Not Hispanic Or Latino Other

Please list your hobbies:

Please describe any medical conditions you have/had:

Please list any medications you are taking, including how often and dosage:

Allergies:

Please describe any medical conditions that occur/have occured within your family, and your relation to these family members: Unknown family history

Review of Systems

Do you have any of the following conditions?

General:	None Other
Ears, Nose, Throat:	none dry mouth cough ear ache hard of hearing stuffy nose Other
Cardiovascular:	none High BP racing pulse Other
Respiratory:	none congestion short of breath wheezing Other
Genital, Kidney, Bladder:	none frequent urination impotence painful urination yellow jaundice Other
Muscles, Bones, Joints:	none arthritis cramps joint pain stiffness swelling Other
Skin:	none growths pimples, warts rash Other
Neurological:	none noted headache numbness, paralysis seizures Other
Psychiatric:	None noted anxiety depression insomnia Other
Endocrine:	no problem diabetes hypothyroid Other
Blood/Lymph:	none anemia bleeding cholestrolemia Other
Allergic/Immunologic	none hives itching lupus redness sneezing swelling Other

Submit Data

You can find a link to our Dilation and HIPAA form here. If possible, please print this, fill it out, and bring it with you when you visit the office. Thank you!