New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
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 Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance 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:

Vision

Insurance Information
Insurance Name:
Insurance 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:
Insurance 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:
Insurance 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:

Chief Complaint


CHIEF COMPLAINT
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Chief Complaint:
Secondary Complaints:
Notes:

REVIEW OF OCULAR SYSTEM

Ocular History Eye Meds:
Doctor: Last Eye Exam:

FAMILY OCULAR HISTORY

Glaucoma: Cataracts: Macular Degen:
Retinal Detach: Crossed / Lazy: Other Family History

NOTES:


Medical History


MEDICAL HISTORY
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REVIEW OF SYSTEMS

GENERAL:
EAR, NOSE, THROAT:
CARDIOVASCULAR:
RESPIRATORY:
GENITAL, KIDNEY, BLADDER:
MUSCLES, BONES, JOINTS:
SKIN:
NEUROLOGICAL:
PSYCHIATRIC:
ENDORCRINE:
BLOOD/LYMPH:
ALLERGIC / IMMUNOLOGIC:
GASTROINTESTINAL:


PATIENT MEDICAL HISTORY

Primary Care Physician: Last Visit: Reason For Visit:

Current Medications:Drug Allergies:
No Current Meds No Known Drug Allergies

Vitamins: Over The Counter Meds:

Injuries, Surgeries, Hospitalization
Notes:
Pregnant Or Nursing:


FAMILY MEDICAL HISTORY

Diabetes: Hypertension: Cancer:
Heart Disease: Other:


SOCIAL HISTORY

Occupation: Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long:
STD:

Submit Data

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