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Monday-Friday: 8:30 a.m. - 5:30 p.m.
Saturday: By Appointment

New Patient Input Form

Patient Information

Title First Last MI Suffix Nickname
Address:
City: State/ZipCode
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 Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
Title First Last MI Suffix
Address

City State ZipCode
Home Phone:
Work Phone:

Primary Medical Insurance

Insurance Information
Insurance Name:
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:

Vision Plan

Insurance Information
Insurance Name:
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:

Secondary Medical Insurance

Insurance Information
Insurance Name:
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



Preferred Language: 

Race 

Smoking Status: 

Age
Occupation:
Referred By:
Patient's Family:
Hobbies:
Ever Worn Contact Lenses?
Are You Interested in Contact Lenses?
Type of Contact Lenses worn in past:
Current Glasses?
Primary Vision Correction:
Hours on computer per day?
Problems with glare?
Eye History:
Eye Medications:
Last Eye Exam:
Family Physician:
Current Medications:
Past Medications:
Family Medical History:
Family Eye History:
Allergies:
General: (If no field applies, choose Negative or none)
Ears, Nose, Throat:
Cardiovascular:
Respiratory:
Genital, Kidney, Bladder:
Muscles, Bones, Joints:
Skin:
Neurological:
Psychiatric:
Endocrine:
Blood/Lymph:
Allergic/Immunologic
NOTES:

Forms

Office Forms

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