New Patient Form

Demographics


Title First Last MI Suffix Nickname

Address1:
Address2:
City:
State/ZipCode  
Home Phone:
Work Phone:
Other Phone:
Alerts:
SSN*
*SSN of primary name on insurance policy. Needed for insurance verification only.
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

Address1
Address2
City
State
ZipCode
Home Phone:
Work Phone:

Primary

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

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:

Tertiary

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

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Referred By:
Pregnant
Smoker
Primary Vision Correction:
Interested In Contact Lens?
Problems with current Contacts?
Interested in LASIK?
Problems with glare?
Last Eye Exam:
EyeTrauma:
Eye Surgery:
Vision Loss:
Double Vision:
Flashes:
Floaters:
Excess tearing:
Burning:
Itching:
Glaucoma:
Cataracts:
Other:
Eye Meds:
Systemic Meds:
Allergies:
Primary Care Physician:
Last Physical Exam:
Hypertension:
Diabetes:
Heart Dz:
Thyroid:
Lung Disease:
Arthritis:
Auto Immune:
Skin:
Gastric:
Urogenital:
Cancer:
Psychiatric:
Neurological:
Blood:
General Health:
Family Medical History:
Family Eye History:
NOTES:

Submit Data

After Completing All Forms Submit Data on Final Tab