New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. 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:
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. Tran, Tam Kim Dr. Bridges, David L. Dr. Norcini, Donald J. Dr. Walkin,	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. 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 AARP ACCUTEST ACORDIA NATIONAL AETNA BCBS CIGNA COMPBENEFITS COST COST PLUS EMPLOYEE PLAN SERVICES EYEMED EYEMED-HP PREM EYEMED-HP STAN EYEMED DIS FISERV GEHA MEDICARE MUTUAL OF OMAHA OTHER PHCS SAFETY SUPERIOR VISION TRADE TRANSAMERICA LIFE INSURANCE UNITED HEALTH CARE VBA-VISION BENEFITS OF AMERICA VCS VISION CARE PLAN VSP VSP-EXAM VSP + ALLOWANCES VSP DISCOUNT
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:	None AARP ACCUTEST ACORDIA NATIONAL AETNA BCBS CIGNA COMPBENEFITS COST COST PLUS EMPLOYEE PLAN SERVICES EYEMED EYEMED-HP PREM EYEMED-HP STAN EYEMED DIS FISERV GEHA MEDICARE MUTUAL OF OMAHA OTHER PHCS SAFETY SUPERIOR VISION TRADE TRANSAMERICA LIFE INSURANCE UNITED HEALTH CARE VBA-VISION BENEFITS OF AMERICA VCS VISION CARE PLAN VSP VSP-EXAM VSP + ALLOWANCES VSP DISCOUNT
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:	None AARP ACCUTEST ACORDIA NATIONAL AETNA BCBS CIGNA COMPBENEFITS COST COST PLUS EMPLOYEE PLAN SERVICES EYEMED EYEMED-HP PREM EYEMED-HP STAN EYEMED DIS FISERV GEHA MEDICARE MUTUAL OF OMAHA OTHER PHCS SAFETY SUPERIOR VISION TRADE TRANSAMERICA LIFE INSURANCE UNITED HEALTH CARE VBA-VISION BENEFITS OF AMERICA VCS VISION CARE PLAN VSP VSP-EXAM VSP + ALLOWANCES VSP DISCOUNT
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

Referred By:

Insurance Friend/Family Website/Internet Yellow Pages Walk-by/Drive-by

Family Patients:

Hobbies:

Interested In Contact Lenses?

Yes No

Ever Worn Contact Lenses?

Yes No

Type of CLs worn in past:

Disposables Extended Wear Gas Permeables Gas Perm Bifocals Gas Perm Bitorics Gas Perm FS Toric Monovision - Soft Monovision - Disposables Monovision - Gas Perm No CL Hx Soft Daily Wear Soft Torics

Primary Vision Correction:

None Bifocals Contacts Contacts - Mono Progressives Single Vision Trifocals

Sunspecs?

Yes No

Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal

Abrasion Blind Eye Blepheroplasty Cataract - OU Cataract - OD Cataract - OS Conjunctivitis Glaucoma IOL - OU IOL - OD IOL - OS Metal in Eye None Ptosis Retinal Detach Weak Eye Lazy Eye

Eye Meds:

Acular Artificial Tears Betoptic-S .25% Betoptic .5% Betagan Erythromycin FML FML Forte Gentamicin Neosporin None Ocupress Pilo Gel Propine Polytrim Pred Mild Pred Forte Patanol Timoptic .25% Timoptic .5% Tobradex Voltaren Xalatan None

Primary Care Physician:

Systemic Meds:

Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Smoke,Pregnant,Nursing,HIV+

Family Med History:

Artheritis Cancer Diabetes I Diabetes II Hypertension Hypercholesterolmia Heart Dx None Known None

Family Eye History:

Amblyopia Cataracts Glaucoma Macular Degeneration Retinal Detachment Weak Eye Lazy Eye None

Medication and Seasonal Allergies:

NKA NKDA Codeine Erythromycin Iodine Pollen PCN Sulfa Seasonal Tetanus

NOTES/SOCIAL HISTORY

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