New Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
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
Unknown
Single
Married
Separated
Divorced
Widowed
Child
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Chumley, Paige
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
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:
Insurance 1
Insurance Information
Insurance Name:
None
AETNA
Block Vision Plan- NOT PROVIDER
Blue Cross Blue Shield Texas
CIGNA
DAVIS VISION PLAN
EYEMED Vision Plan
Humana
Medicaid TMHP
Medicare Part B
OPTUM Vision Plan
SUPERIOR VISION PLAN
TEXAS PLUS HMO/ WE DONT TAKE
TML Intergovernmental Employee Benefits Pool
United Health Care
VSP Vision 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:
Employer/School:
Insurance 2
Insurance Information
Insurance Name:
None
AETNA
Block Vision Plan- NOT PROVIDER
Blue Cross Blue Shield Texas
CIGNA
DAVIS VISION PLAN
EYEMED Vision Plan
Humana
Medicaid TMHP
Medicare Part B
OPTUM Vision Plan
SUPERIOR VISION PLAN
TEXAS PLUS HMO/ WE DONT TAKE
TML Intergovernmental Employee Benefits Pool
United Health Care
VSP Vision 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:
Employer/School:
Insurance 3
Insurance Information
Insurance Name:
None
AETNA
Block Vision Plan- NOT PROVIDER
Blue Cross Blue Shield Texas
CIGNA
DAVIS VISION PLAN
EYEMED Vision Plan
Humana
Medicaid TMHP
Medicare Part B
OPTUM Vision Plan
SUPERIOR VISION PLAN
TEXAS PLUS HMO/ WE DONT TAKE
TML Intergovernmental Employee Benefits Pool
United Health Care
VSP Vision 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:
Employer/School:
Medical History
Age:
Race
Gender
Female
Male
Occupation:
Employer:
Referred By:
Pregnant
No
Yes
Smoker
No
Yes
Hobbies
Spouse/Parent Name:
Primary Vision Correction:
None
Eye glasses
Soft Contact lenses
Hard Contact Lenses
Glasses & Contact lenses
Interested In CL?
Ever Worn CL?
No
Yes
Current CL type:
Problems with current CL?
Interested in Refractive Sx?
No
Yes
Problems with glare?
No
Yes
Computer use
1-2 hrs/day
3-6 hrs/day
>6 hrs/day
None
General Eye Health
:
Last Eye Exam:
Last Eye Doctor:
EyeTrauma:
No
Yes
Eye Surgery:
No
Yes
Vision Loss:
No
Yes
Diplopia:
No
Yes
Flashes:
No
Yes
Floaters:
No
Yes
Water:
No
Yes
Burn:
No
Yes
Itch:
No
Yes
Glaucoma:
No
Yes
Cataracts:
No
Yes
Other:
Eye Meds:
Systemic Meds:
Allergies:
General Systemic Health
:
Primary Care Physician:
Last Physical Exam:
Hypertension:
No
Yes
Diabetes:
Heart Dz:
No
Yes
Thyroid:
No
Yes
Lung Dz:
No
Yes
Arthritis:
No
Yes
Auto Immune:
No
Yes
Skin:
No
Yes
Gastric:
No
Yes
Urogenital:
No
Yes
Cancer:
No
Yes
Psych:
No
Yes
Neuro:
No
Yes
Blood:
No
Yes
Gen Health:
Family Med History:
Family Eye History:
NOTES: