New Patient Form

Demographics

TitleFirstLastMISuffixNickname
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?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary 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 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:

Primary Medical

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 Medical

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:

Medical History

How did you hear about us:
Referring Doctor:
Family Patients:
Hobbies:
Primary Vision Correction:
Interested In Contact Lenses?
Type of CLs worn in past:
Do you have back up glasses for CLs?
Are you planning on updating your glasses today?
Do you have vision probelms during any specific activity?
How many hours/day are you on a computer?
Do you have computer specs?
Do you have prescription Sunglasses?
Do you have problems with glare?
Do you prefer not wearing you glasses at times?
Interested in newer contact lens technology?
Want information on thinner/lighter lenses?
Want information on LASIK surgery?
Want information on a non-surgical alternative to LASIK?
Drug / Seasonal Allergies
Eye History: Dry Eyes, Red Eyes, , Surgeries., Cataracts, Glaucoma, Macular degeneration, Etc.
Eye Medications:
Last Eye Doctor:
Primary Care Physician:
Systemic Meds:
Family Medication History:
Family Eye History:
Do you Smoke? If so, how much?
Do you drink alcohol? If so, how much?
Do you use recreational drugs? If so, explain?

Review of Systems


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

Do you currently have any of these problems?
General:
Ears, Nose, Throat:
Cardiovascular:
Respiratory:
Genital, Kidney, Bladder:
Muscles, Bones, Joints:
Skin:
Neurological:
Psychiatric:
Endocrine:
Blood/Lymph:
Allergic/Immunologic
Mood:

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